Provider Demographics
NPI:1891855409
Name:BUCK, STEPHANIE MARY (PHD, MACP)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:MARY
Last Name:BUCK
Suffix:
Gender:F
Credentials:PHD, MACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 S MILLS ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1851
Mailing Address - Country:US
Mailing Address - Phone:608-886-6478
Mailing Address - Fax:866-298-4159
Practice Address - Street 1:831 S MILLS ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1851
Practice Address - Country:US
Practice Address - Phone:608-886-6478
Practice Address - Fax:866-298-4159
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000236101YM0800X
WI4801-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1891855409Medicaid