Healthcare Provider Details

I. General information

NPI: 1033239918
Provider Name (Legal Business Name): MARA STEPHANIE BRUCKNER M.A., M.F.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6340 VARIEL AVE SUITE A
WOODLAND HILLS CA
91367-2514
US

IV. Provider business mailing address

22040 VISCANIO RD
WOODLAND HILLS CA
91364-4110
US

V. Phone/Fax

Practice location:
  • Phone: 818-725-7924
  • Fax: 818-888-4005
Mailing address:
  • Phone: 818-725-7924
  • Fax: 818-713-0923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC36105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: