Provider Demographics
NPI:1215332028
Name:CANDACE BUCKLEY
Entity type:Organization
Organization Name:CANDACE BUCKLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BUCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:262-501-0770
Mailing Address - Street 1:W228S2323 ORIOLE DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-6371
Mailing Address - Country:US
Mailing Address - Phone:262-501-0770
Mailing Address - Fax:
Practice Address - Street 1:W228S2323 ORIOLE DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-6371
Practice Address - Country:US
Practice Address - Phone:262-501-0770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7921261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)