Provider Demographics
NPI:1568862431
Name:BUCK, SHIRLEY
Entity Type:Individual
Prefix:
First Name:SHIRLEY
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 1:5739 W EASTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3309
Mailing Address - Country:US
Mailing Address - Phone:773-615-1651
Mailing Address - Fax:
Practice Address - Street 1:7311 W FOREST PRESERVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-3505
Practice Address - Country:US
Practice Address - Phone:773-625-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.012109225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist