=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013469600
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY MARIE BUCK LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2016
-----------------------------------------------------
Last Update Date | 03/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 W PARK AVE
-----------------------------------------------------
City | DU BOIS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15801-2452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-771-5254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 564
-----------------------------------------------------
City | HYDE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16843-0564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-771-5254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | SW133530
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CW021637
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------