Healthcare Provider Details

I. General information

NPI: 1255975546
Provider Name (Legal Business Name): CAMILLE BULACLAC LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2019
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 GREAT AMERICA PKWY STE 320
SANTA CLARA CA
95054-1140
US

IV. Provider business mailing address

22295 TORINO
LAGUNA HILLS CA
92653-1920
US

V. Phone/Fax

Practice location:
  • Phone: 323-205-7088
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number121323
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: