Healthcare Provider Details

I. General information

NPI: 1629019385
Provider Name (Legal Business Name): ELIZABETH ANN BUCK LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9117 REDMONT RD NE
ALBUQUERQUE NM
87109-6812
US

IV. Provider business mailing address

9117 REDMONT RD NE
ALBUQUERQUE NM
87109-6812
US

V. Phone/Fax

Practice location:
  • Phone: 505-821-3505
  • Fax:
Mailing address:
  • Phone: 505-821-3505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0075491
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: