Healthcare Provider Details

I. General information

NPI: 1750699591
Provider Name (Legal Business Name): KIMBERLY KAY BUKSA MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 KELLER ST SUITE D
PETALUMA CA
94952-2349
US

IV. Provider business mailing address

314 BOND AVE
PETALUMA CA
94954-5647
US

V. Phone/Fax

Practice location:
  • Phone: 707-776-6414
  • Fax:
Mailing address:
  • Phone: 415-623-9514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number92609
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: