Provider Demographics
NPI:1033239918
Name:BRUCKNER, MARA STEPHANIE (MA, MFT)
Entity Type:Individual
Prefix:MS
First Name:MARA
Middle Name:STEPHANIE
Last Name:BRUCKNER
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22040 VISCANIO RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-4110
Mailing Address - Country:US
Mailing Address - Phone:818-725-7924
Mailing Address - Fax:818-713-0923
Practice Address - Street 1:6340 VARIEL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-2514
Practice Address - Country:US
Practice Address - Phone:818-725-7924
Practice Address - Fax:818-888-4005
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC36105106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist