Healthcare Provider Details

I. General information

NPI: 1750946745
Provider Name (Legal Business Name): MATTHEW VERNON BUKOWSKI LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2019
Last Update Date: 03/03/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E MARKET ST
CHARLOTTESVILLE VA
22902-5381
US

IV. Provider business mailing address

134 LEAKE LN
CHARLOTTESVILLE VA
22902-5476
US

V. Phone/Fax

Practice location:
  • Phone: 434-270-0571
  • Fax: 240-595-6198
Mailing address:
  • Phone: 434-270-0571
  • Fax: 240-595-6198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701007508
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701007508
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0701007508
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: