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General NPI Number Information
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NPI Number | 1609438639
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Entity Type | Individual
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Provider Name | MARLON J BUCKLEY SR.
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Gender | Male
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Dates
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Enumeration Date | 06/29/2019
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Last Update Date | 06/29/2019
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Provider Practice Location Address
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Address Line | 800 ZORN AVE
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City | LOUISVILLE
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State | KY
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Zip | 40206-1433
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Country | US
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Telephone | 502-287-6172
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Fax |
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Provider Business Mailing Address
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Address Line | 109 AZALEA CT
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City | CLARKSVILLE
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State | TN
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Zip | 37042-3495
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Country | US
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Telephone | 615-838-2938
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | LSW0000011022
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License Number State | TN
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