Provider Demographics
NPI:1316573512
Name:BUCK, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 LYONS AVE
Mailing Address - Street 2:TLC- OUTPATIENT PROGRAM
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112
Mailing Address - Country:US
Mailing Address - Phone:973-926-7812
Mailing Address - Fax:973-926-2943
Practice Address - Street 1:201 LYONS AVE
Practice Address - Street 2:TLC- OUTPATIENT PROGRAM
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112
Practice Address - Country:US
Practice Address - Phone:973-926-7812
Practice Address - Fax:973-926-2943
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06405900104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker