MEDICARE: MARY KATHLEEN BUCKLEY 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	LCSW11572	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	CA21889391	OTHER	CA	ANTHEM BLUE CROSS
3	ZZZ26585Z	OTHER	CA	BLUE SHIELD OF CALIFORNIA

General Provider Information

NPI Number	:	1992045439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KATHLEEN BUCKLEY LCSW

Provider Business Mailing Address
First Line	:	1357 W SHAW AVE STE 102
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93711-3619
Country	:	US
Telephone Number	:	559-250-6715
Fax Number	:	866-812-5195

Provider Business Practice Location Address
First Line	:	1357 W SHAW AVE STE 102
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93711-3619
Country	:	US
Telephone Number	:	559-464-5279
Fax Number	:	866-812-5195

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

Provider Enumeration Date	:	02/20/2013
Last Update Date	:	06/13/2024

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