MEDICARE: DR. DWAYNE LAMONT BUCKINGHAM M.S.W, PHD

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	1041C0700X	Clinical Social Worker	2006029483	MO
2	1041C0700X	Clinical Social Worker	6801076311	MI
3	1041C0700X	Clinical Social Worker	22698	MD

General Provider Information

NPI Number	:	1578555397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DWAYNE LAMONT BUCKINGHAM M.S.W, PHD

Provider Business Mailing Address
First Line	:	9524 BALTIMORE AVE
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20723
Country	:	US
Telephone Number	:	210-382-2672
Fax Number	:

Provider Business Practice Location Address
First Line	:	9524 BALTIMORE AVE
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20723-1816
Country	:	US
Telephone Number	:	210-382-2672
Fax Number	:

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	07/21/2022

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