MEDICARE: MS. LOREN SANDY BUCKNER LCSW

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	SW1635	FL

General Provider Information

NPI Number	:	1790791234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LOREN SANDY BUCKNER LCSW

Provider Business Mailing Address
First Line	:	2805 W BUSCH BLVD
Second Line	:	SUITE 113
City	:	TAMPA
State	:	FL
Zip	:	33618-4560
Country	:	US
Telephone Number	:	813-915-0076
Fax Number	:	813-933-3713

Provider Business Practice Location Address
First Line	:	2805 W BUSCH BLVD
Second Line	:	SUITE 113
City	:	TAMPA
State	:	FL
Zip	:	33618-4560
Country	:	US
Telephone Number	:	813-915-0076
Fax Number	:	813-933-3713

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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