=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225758261
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH BUCKLEY PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2022
-----------------------------------------------------
Last Update Date | 08/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3521 SILVERSIDE RD BLDG SUITE
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19810-4900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-219-7912
-----------------------------------------------------
Fax | 302-224-1402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 YORK RD
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19803-3735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-743-6198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | B1-0011348
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------