Provider Demographics
NPI:1245544162
Name:BUCK, ERNESTINA S (PHD)
Entity type:Individual
Prefix:
First Name:ERNESTINA
Middle Name:S
Last Name:BUCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4171
Mailing Address - Street 2:
Mailing Address - City:BISBEE
Mailing Address - State:AZ
Mailing Address - Zip Code:85603-4171
Mailing Address - Country:US
Mailing Address - Phone:520-227-3695
Mailing Address - Fax:855-568-6439
Practice Address - Street 1:33 SUBWAY ST
Practice Address - Street 2:
Practice Address - City:BISBEE
Practice Address - State:AZ
Practice Address - Zip Code:85603
Practice Address - Country:US
Practice Address - Phone:520-227-3695
Practice Address - Fax:855-568-6439
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-1608101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional