Provider Demographics
NPI:1811597008
Name:BUCK, ANDREA M (DP-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:BUCK
Suffix:
Gender:F
Credentials:DP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52493 STORBAELT LN
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-3605
Mailing Address - Country:US
Mailing Address - Phone:586-839-9258
Mailing Address - Fax:
Practice Address - Street 1:4301 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-6411
Practice Address - Country:US
Practice Address - Phone:586-788-6236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer