Provider Demographics
NPI:1316795032
Name:BUCKLE, KERRY DEAN (LCSW)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:DEAN
Last Name:BUCKLE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5622 34TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7879
Mailing Address - Country:US
Mailing Address - Phone:701-306-9855
Mailing Address - Fax:
Practice Address - Street 1:5622 34TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7879
Practice Address - Country:US
Practice Address - Phone:701-237-0942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND51401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical