Provider Demographics
NPI:1306305578
Name:BUCKMAN, EDMUND TAYLOE IV (LCASA, LPCA)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:TAYLOE
Last Name:BUCKMAN
Suffix:IV
Gender:M
Credentials:LCASA, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 CAPITAL BLVD APT 213
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-1157
Mailing Address - Country:US
Mailing Address - Phone:252-943-1536
Mailing Address - Fax:
Practice Address - Street 1:614 CAPITAL BLVD APT 213
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-1157
Practice Address - Country:US
Practice Address - Phone:252-943-1536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25328101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor