Healthcare Provider Details

I. General information

NPI: 1174843072
Provider Name (Legal Business Name): DEBORAH BUKOLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2772 4TH AVE
SAN DIEGO CA
92103-6206
US

IV. Provider business mailing address

355 C AVE
CORONADO CA
92118-1405
US

V. Phone/Fax

Practice location:
  • Phone: 619-295-6067
  • Fax:
Mailing address:
  • Phone: 619-319-7789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: