Healthcare Provider Details

I. General information

NPI: 1275861114
Provider Name (Legal Business Name): ELIZABETH MARIE BUCOLO M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2009
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N UNIVERSITY AVE SUITE 200
LITTLE ROCK AR
72207-6343
US

IV. Provider business mailing address

1100 N UNIVERSITY AVE SUITE 200
LITTLE ROCK AR
72207-6343
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-9300
  • Fax: 501-663-0450
Mailing address:
  • Phone: 501-686-9300
  • Fax: 501-663-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number14-15 LP
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: