Healthcare Provider Details

I. General information

NPI: 1740416619
Provider Name (Legal Business Name): MARCIA KULLBACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2009
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5284 ADOLFO RD
CAMARILLO CA
93012
US

IV. Provider business mailing address

5284 ADOLFO RD
CAMARILLO CA
93012-6787
US

V. Phone/Fax

Practice location:
  • Phone: 805-289-0120
  • Fax:
Mailing address:
  • Phone: 805-289-0120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10162
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: