Healthcare Provider Details

I. General information

NPI: 1194094862
Provider Name (Legal Business Name): BROOKE BUCK MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2011
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8607 WURZBACH RD SUITE V-104
SAN ANTONIO TX
78240-1303
US

IV. Provider business mailing address

19141 STONE OAK PKWY STE 104
SAN ANTONIO TX
78258-3367
US

V. Phone/Fax

Practice location:
  • Phone: 210-697-3300
  • Fax: 210-424-0106
Mailing address:
  • Phone: 210-391-0030
  • Fax: 210-497-2104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number66220
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number66220
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: