Provider Demographics
NPI:1316445745
Name:BUCKLEY, SHANNON (MA, LAC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 W BURLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BORDENTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08505-1722
Mailing Address - Country:US
Mailing Address - Phone:609-752-1518
Mailing Address - Fax:
Practice Address - Street 1:342 EGG HARBOR RD STE B
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-1856
Practice Address - Country:US
Practice Address - Phone:856-589-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00385300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health