Healthcare Provider Details

I. General information

NPI: 1568750784
Provider Name (Legal Business Name): ANGELA POWELL-BULUTOGLU LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2011
Last Update Date: 03/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N SAN MATEO DR STE 5
SAN MATEO CA
94401-2674
US

IV. Provider business mailing address

PO BOX 1819
ROHNERT PARK CA
94927-1819
US

V. Phone/Fax

Practice location:
  • Phone: 707-779-9132
  • Fax:
Mailing address:
  • Phone: 707-585-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number903854
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: