Provider Demographics
NPI:1629159611
Name:BUCK, RETHA A (MSW LCSW)
Entity Type:Individual
Prefix:MS
First Name:RETHA
Middle Name:A
Last Name:BUCK
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY PLACE
Mailing Address - Street 2:APT 15F
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10003
Mailing Address - Country:US
Mailing Address - Phone:212-982-1315
Mailing Address - Fax:212-982-1315
Practice Address - Street 1:817 BROADWAY
Practice Address - Street 2:STE. 918
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4709
Practice Address - Country:US
Practice Address - Phone:212-982-1315
Practice Address - Fax:212-982-1315
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR00547611041C0700X
NJ44SC000937001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJBU636715Medicare ID - Type Unspecified
NYN797R1Medicare PIN