Provider Demographics
NPI:1841313418
Name:BUCK, GARY L (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:BUCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 BRODY PL
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-7421
Mailing Address - Country:US
Mailing Address - Phone:707-789-9357
Mailing Address - Fax:707-789-9357
Practice Address - Street 1:921 TRANSPORT WAY STE 33
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-1464
Practice Address - Country:US
Practice Address - Phone:415-755-5742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27298103T00000X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical