Healthcare Provider Details

I. General information

NPI: 1790690717
Provider Name (Legal Business Name): CORY BUCKNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22436 CANTERBURY ST
WOODHAVEN MI
48183-1458
US

IV. Provider business mailing address

22436 CANTERBURY ST
WOODHAVEN MI
48183-1458
US

V. Phone/Fax

Practice location:
  • Phone: 734-510-0786
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401224451
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: