Provider Demographics
NPI:1942975743
Name:BUCKHAM, LATANYA
Entity type:Individual
Prefix:
First Name:LATANYA
Middle Name:
Last Name:BUCKHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-1803
Mailing Address - Country:US
Mailing Address - Phone:347-674-0768
Mailing Address - Fax:
Practice Address - Street 1:205 HUDSON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-1803
Practice Address - Country:US
Practice Address - Phone:347-674-0768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013763101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health