Healthcare Provider Details

I. General information

NPI: 1790494185
Provider Name (Legal Business Name): AGNE SOFIA BOLSAKOVA MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1826 KEY LARGO RD
VISTA CA
92081-7004
US

IV. Provider business mailing address

1826 KEY LARGO RD
VISTA CA
92081-7004
US

V. Phone/Fax

Practice location:
  • Phone: 760-420-8739
  • Fax:
Mailing address:
  • Phone: 760-420-8739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number18741
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: