Provider Demographics
NPI:1376024505
Name:RUCKER, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:RUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 SPRING ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-1317
Mailing Address - Country:US
Mailing Address - Phone:347-946-7015
Mailing Address - Fax:
Practice Address - Street 1:530 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12305-2008
Practice Address - Country:US
Practice Address - Phone:518-292-5499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-26
Last Update Date:2024-01-11
Deactivation Date:2019-11-07
Deactivation Code:
Reactivation Date:2020-11-04
Provider Licenses
StateLicense IDTaxonomies
NY106213104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker