Healthcare Provider Details

I. General information

NPI: 1316445745
Provider Name (Legal Business Name): SHANNON BUCKLEY MA, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 01/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 EGG HARBOR RD STE B
SEWELL NJ
08080-1856
US

IV. Provider business mailing address

9 W BURLINGTON ST
BORDENTOWN NJ
08505-1722
US

V. Phone/Fax

Practice location:
  • Phone: 856-589-3420
  • Fax:
Mailing address:
  • Phone: 609-752-1518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00385300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: