Provider Demographics
NPI:1558124123
Name:BUUCK, MALLORY (LCSW)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:BUUCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 SAINT JULIEN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4655
Mailing Address - Country:US
Mailing Address - Phone:337-706-1940
Mailing Address - Fax:
Practice Address - Street 1:309 SAINT JULIEN AVE STE 201
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4655
Practice Address - Country:US
Practice Address - Phone:337-706-3415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16535104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker