Basic Information
Provider Information | |||||||||
NPI: | 1952479495 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUCCINO | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW, LCSW-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 711 W 40TH ST | ||||||||
Address2: | SUITE 456 | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212112120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4102359200 | ||||||||
FaxNumber: | 4102359339 | ||||||||
Practice Location | |||||||||
Address1: | 711 W 40TH ST | ||||||||
Address2: | SUITE 456 | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212112120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4102359200 | ||||||||
FaxNumber: | 4102359339 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/01/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 07046 | MD | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 25129 | 01 | MD | EHP PIN | OTHER | R0260001 | 01 | MD | CFBCBS PIN | OTHER | 25299 | 01 | MD | CIGNA BEHAVIORAL PIN | OTHER |