Provider Demographics
NPI:1598175457
Name:RUCKER, CEDRIC CHAUNCEY (MA,MDIV)
Entity type:Individual
Prefix:MR
First Name:CEDRIC
Middle Name:CHAUNCEY
Last Name:RUCKER
Suffix:
Gender:M
Credentials:MA,MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 WALDECK ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-1318
Mailing Address - Country:US
Mailing Address - Phone:757-553-7547
Mailing Address - Fax:
Practice Address - Street 1:61 WALDECK ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-1318
Practice Address - Country:US
Practice Address - Phone:757-553-7547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health