Healthcare Provider Details

I. General information

NPI: 1598818312
Provider Name (Legal Business Name): COLETTE A BUKOWSKI LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34900 CHARDON RD SUITE 102
WILLOUGHBY OH
44094-9161
US

IV. Provider business mailing address

1760 SUNVIEW RD
LYNDHURST OH
44124-2843
US

V. Phone/Fax

Practice location:
  • Phone: 216-548-1439
  • Fax:
Mailing address:
  • Phone: 440-473-0230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE4173
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: