Provider Demographics
NPI:1972769560
Name:BUCKLEY, LISA ANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:BUCKLEY
Suffix:
Gender:F
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:PO BOX 451
Mailing Address - Street 2:
Mailing Address - City:REDDINGRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06876
Mailing Address - Country:US
Mailing Address - Phone:203-470-0043
Mailing Address - Fax:
Practice Address - Street 1:152 DEER HILL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-470-0043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-03
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0067901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT021100361Medicaid