Healthcare Provider Details

I. General information

NPI: 1689882656
Provider Name (Legal Business Name): TODD EDWARD BUCK MHPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20400 COLONEL GLENN RD
LITTLE ROCK AR
72210-5323
US

IV. Provider business mailing address

16 ROARING RIVER LOOP
HOUSTON AR
72070-8124
US

V. Phone/Fax

Practice location:
  • Phone: 501-821-5500
  • Fax:
Mailing address:
  • Phone: 501-551-0686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: