Provider Demographics
NPI:1427756030
Name:BUCKHOLZ, BRODERICK DANIEL BLUES (BA)
Entity type:Individual
Prefix:MR
First Name:BRODERICK
Middle Name:DANIEL BLUES
Last Name:BUCKHOLZ
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
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Mailing Address - Street 1:2620 POTTER ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-4124
Mailing Address - Country:US
Mailing Address - Phone:503-383-2481
Mailing Address - Fax:
Practice Address - Street 1:37875 JASPER LOWELL RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:OR
Practice Address - Zip Code:97438-9751
Practice Address - Country:US
Practice Address - Phone:541-747-1235
Practice Address - Fax:541-747-4722
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health