Healthcare Provider Details

I. General information

NPI: 1063718112
Provider Name (Legal Business Name): CATHERINE BERYL BUCKLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2011
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4513
US

V. Phone/Fax

Practice location:
  • Phone: 401-273-8100
  • Fax: 401-861-8696
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberISW02874
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: