Provider Demographics
NPI:1043664832
Name:BUCK, RANDALL LEE
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:LEE
Last Name:BUCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 E. WILMOT RD.
Mailing Address - Street 2:BLDG B
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711
Mailing Address - Country:US
Mailing Address - Phone:520-290-1100
Mailing Address - Fax:520-290-8997
Practice Address - Street 1:899 E. WILMOT RD.
Practice Address - Street 2:BLDG B
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711
Practice Address - Country:US
Practice Address - Phone:520-290-1100
Practice Address - Fax:520-290-8997
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2019101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional