Healthcare Provider Details

I. General information

NPI: 1508152497
Provider Name (Legal Business Name): DANIELLE BUCKLEMAN LMSW, CASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DANIELLE GIBBONS

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WINGED FOOT DR
MEDFORD NY
11763-1804
US

IV. Provider business mailing address

10 WINGED FOOT DR
MEDFORD NY
11763-1804
US

V. Phone/Fax

Practice location:
  • Phone: 631-617-2919
  • Fax:
Mailing address:
  • Phone: 631-617-2919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24082
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number080654
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: