Healthcare Provider Details

I. General information

NPI: 1083286058
Provider Name (Legal Business Name): MONIQUE BRIGITTE BUKLAN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2021
Last Update Date: 07/11/2021
Certification Date: 07/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 ALLENDALE RD STE 322
KING OF PRUSSIA PA
19406-1432
US

IV. Provider business mailing address

2201 BRYN MAWR AVE APT 805
PHILADELPHIA PA
19131-2112
US

V. Phone/Fax

Practice location:
  • Phone: 610-544-2110
  • Fax:
Mailing address:
  • Phone: 347-466-6325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS019315
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: