Basic Information
| Provider Information | |||||||||
| NPI: | 1053427948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKLEY | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUCKLEY | ||||||||
| OtherFirstName: | ANITA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | MARCUS HOOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190614513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108598850 | ||||||||
| FaxNumber: | 6108597876 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 GREAT VALLEY PKWY | ||||||||
| Address2: | STE 140 | ||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193551300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109816411 | ||||||||
| FaxNumber: | 6109816402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 05/27/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01101900 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT-020453 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1750739 | 01 | PA | PA BLUE SHIELD | OTHER | 102567448-0001 | 05 | PA | MEDICAID |