MEDICARE: PEGGY BOLCOA MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC28920	CA

General Provider Information

NPI Number	:	1639270648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PEGGY BOLCOA MFT

Provider Business Mailing Address
First Line	:	2900 BRISTOL ST STE J101
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-7918
Country	:	US
Telephone Number	:	714-436-1800
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 BRISTOL ST STE J101
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-7918
Country	:	US
Telephone Number	:	714-436-1800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/08/2007

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