Provider Demographics
NPI:1649565656
Name:BUCKLEY, LARA COLLEEN (PSYD)
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:COLLEEN
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 N WOOD RD STE 302
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-8312
Mailing Address - Country:US
Mailing Address - Phone:805-910-5382
Mailing Address - Fax:
Practice Address - Street 1:1756 S LEWIS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8520
Practice Address - Country:US
Practice Address - Phone:805-383-3669
Practice Address - Fax:805-383-3692
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
CAPSY33291103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA174400000XOtherOTHER