Provider Demographics
NPI:1215783535
Name:BUCKLEY, MARIE (LDP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:LDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17950 SUNMEADOW DR APT 4801
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-5390
Mailing Address - Country:US
Mailing Address - Phone:602-881-0528
Mailing Address - Fax:
Practice Address - Street 1:17950 SUNMEADOW DR APT 4801
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-5390
Practice Address - Country:US
Practice Address - Phone:602-881-0528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11432084P0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities