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NPI Code Detail

MEDICARE: MR. DAVID BRUCE BUCKNAM LCPC

MEDICARE: MR. DAVID BRUCE BUCKNAM LCPC
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
1101YP2500XProfessional Counselor180-001583IL

General Provider Information

NPI Number : 1760516207
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. DAVID BRUCE BUCKNAM LCPC
Provider Business Mailing Address
First Line : 33494 N LAKE SHORE DR
Second Line :
City : GRAYSLAKE
State : IL
Zip : 60030-1782
Country : US
Telephone Number : 847-543-1369
Fax Number : 847-577-4306
Provider Business Practice Location Address
First Line : 6615 N BIG HOLLOW RD
Second Line :
City : PEORIA
State : IL
Zip : 61615-2450
Country : US
Telephone Number : 309-692-6622
Fax Number : 93-692-6952
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/15/2007
Last Update Date : 12/07/2025

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