Basic Information
Provider Information | |||||||||
NPI: | 1184083750 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUCKWALD | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | B.S., CADC II, CGACI | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1121 | ||||||||
Address2: |   | ||||||||
City: | ROSEBURG | ||||||||
State: | OR | ||||||||
PostalCode: | 974700254 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5416722691 | ||||||||
FaxNumber: | 5416735642 | ||||||||
Practice Location | |||||||||
Address1: | 400 VIRGINIA AVE | ||||||||
Address2: | #201 | ||||||||
City: | NORTH BEND | ||||||||
State: | OR | ||||||||
PostalCode: | 974592709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417510357 | ||||||||
FaxNumber: | 5417519985 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2016 | ||||||||
LastUpdateDate: | 02/11/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 95-10-68 | OR | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.