Provider Demographics
NPI:1346776192
Name:BUCK, KELLY K
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:K
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 1:737 MARIETTA AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-3437
Mailing Address - Country:US
Mailing Address - Phone:717-736-0656
Mailing Address - Fax:
Practice Address - Street 1:221 RACE ST APT 5
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:PA
Practice Address - Zip Code:17502-9013
Practice Address - Country:US
Practice Address - Phone:717-736-0656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA010616225700000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician