Provider Demographics
NPI:1902877764
Name:BUCKNER, ROSE L (EDD)
Entity type:Individual
Prefix:DR
First Name:ROSE
Middle Name:L
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1159 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-2616
Mailing Address - Country:US
Mailing Address - Phone:417-864-6500
Mailing Address - Fax:417-864-6519
Practice Address - Street 1:1159 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2616
Practice Address - Country:US
Practice Address - Phone:417-864-6500
Practice Address - Fax:417-864-6519
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00222103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical