Provider Demographics
NPI:1417569765
Name:BUCK, ERIN MICHELLE (LADC)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:MICHELLE
Last Name:BUCK
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2533
Mailing Address - Country:US
Mailing Address - Phone:612-275-2817
Mailing Address - Fax:
Practice Address - Street 1:1619 DAYTON AVE STE 325
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6495
Practice Address - Country:US
Practice Address - Phone:763-228-4752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305741101YA0400X
MN3829101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNL352176881710OtherDRIVERS LICENSE