Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | OH1249247 | OH |
NPI | 1053710020 |
---|---|
Provider Name | Mark Buckley |
First Address | Painesville, OH 44077-5323 |
Second Address | Painesville, OH 44077-5323 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2014 |
Last Update Date | 15/08/2014 |