Provider Demographics
NPI:1750755625
Name:BUCK, EDWARD DANIEL (LCSW)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:DANIEL
Last Name:BUCK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 E LAKE ST
Mailing Address - Street 2:#203
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-2890
Mailing Address - Country:US
Mailing Address - Phone:708-567-8748
Mailing Address - Fax:708-777-1623
Practice Address - Street 1:240 E LAKE ST
Practice Address - Street 2:#203
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2890
Practice Address - Country:US
Practice Address - Phone:708-567-8748
Practice Address - Fax:708-777-1623
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0033121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical