Provider Demographics
NPI:1194337022
Name:BUCKWALTER, LORETTA E
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:E
Last Name:BUCKWALTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 RIDGEWOOD RD W
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-6131
Mailing Address - Country:US
Mailing Address - Phone:937-532-3379
Mailing Address - Fax:
Practice Address - Street 1:4401 RIDGEWOOD RD W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-6131
Practice Address - Country:US
Practice Address - Phone:937-532-3379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0008495-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical