Healthcare Provider Details

I. General information

NPI: 1497390066
Provider Name (Legal Business Name): ANGELINE BAUCOM LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2019
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2717 A. ST
JULIAN CA
92036
US

IV. Provider business mailing address

993 POSTAL WAY
VISTA CA
92083-6945
US

V. Phone/Fax

Practice location:
  • Phone: 619-662-4100
  • Fax: 760-765-1278
Mailing address:
  • Phone: 760-630-9922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number117454
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number138739
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number22473
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: