MEDICARE: ELIZABETH BUCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	PSY19584	CA
2	103T00000X	Psychologist	PSY19584	CA

General Provider Information

NPI Number	:	1811005465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH BUCK

Provider Business Mailing Address
First Line	:	200 24TH ST
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94804-1804
Country	:	US
Telephone Number	:	510-412-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 BERKELEY PARK BLVD
Second Line	:	STE 3
City	:	KENSINGTON
State	:	CA
Zip	:	94707
Country	:	US
Telephone Number	:	415-206-5290
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	05/19/2018

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