MEDICARE: MS. VANJA PETROMAN BUCKLEY MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1447408927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VANJA PETROMAN BUCKLEY MSW

Provider Business Mailing Address
First Line	:	1053 S BIG BEND BLVD
Second Line	:	#200
City	:	ST. LOUIS
State	:	MO
Zip	:	63117
Country	:	US
Telephone Number	:	636-549-7700
Fax Number	:

Provider Business Practice Location Address
First Line	:	1053 S BIG BEND BLVD
Second Line	:	#200
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-1605
Country	:	US
Telephone Number	:	636-549-7700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2008
Last Update Date	:	10/01/2016

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