Healthcare Provider Details

I. General information

NPI: 1477747640
Provider Name (Legal Business Name): MARI SHONE BUKOFSKY M.F.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4419 COLDWATER CANYON AVE SUITE J
STUDIO CITY CA
91604-1458
US

IV. Provider business mailing address

16463 BOSQUE DR
ENCINO CA
91436-3719
US

V. Phone/Fax

Practice location:
  • Phone: 818-990-3292
  • Fax:
Mailing address:
  • Phone: 818-990-3292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMI 24290
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: