Basic Information
| Provider Information | |||||||||
| NPI: | 1154989127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKLEY | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 HAHN DR APT B | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953560697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096023830 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6501 COYLE AVE | ||||||||
| Address2: | |||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956080306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165375000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2019 | ||||||||
| LastUpdateDate: | 06/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | 37377 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.