Provider Demographics
NPI:1689720492
Name:BUCKER, ALYCE
Entity Type:Individual
Prefix:
First Name:ALYCE
Middle Name:
Last Name:BUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYCE
Other - Middle Name:
Other - Last Name:BUCKER-COSART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3502 KURTZ ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4431
Mailing Address - Country:US
Mailing Address - Phone:619-718-7800
Mailing Address - Fax:
Practice Address - Street 1:3502 KURTZ ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4431
Practice Address - Country:US
Practice Address - Phone:619-718-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS237851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical