Healthcare Provider Details

I. General information

NPI: 1669873055
Provider Name (Legal Business Name): STEPHANIE SUZANNE BOUC PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26485 CARMEL RANCHO BLVD STE 5
CARMEL CA
93923-8706
US

IV. Provider business mailing address

250 COUNTRY CLUB HTS
CARMEL VALLEY CA
93924-9560
US

V. Phone/Fax

Practice location:
  • Phone: 831-235-7758
  • Fax:
Mailing address:
  • Phone: 831-235-7758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY 16275
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: