Provider Demographics
NPI:1790221737
Name:RUCKER, ANTHONY C (MS)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:C
Last Name:RUCKER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13601 WHITTIER BLVD
Mailing Address - Street 2:STE 310
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90605-1902
Mailing Address - Country:US
Mailing Address - Phone:917-754-3691
Mailing Address - Fax:
Practice Address - Street 1:13601 WHITTIER BLVD
Practice Address - Street 2:STE 310
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90605-1902
Practice Address - Country:US
Practice Address - Phone:917-754-3691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-15
Last Update Date:2017-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94023171103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist