Provider Demographics
NPI:1518689066
Name:BURACK, FROMA
Entity Type:Individual
Prefix:
First Name:FROMA
Middle Name:
Last Name:BURACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 RADCLIFFE AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3510
Mailing Address - Country:US
Mailing Address - Phone:310-990-2199
Mailing Address - Fax:
Practice Address - Street 1:12304 SANTA MONICA BLVD STE 209
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2587
Practice Address - Country:US
Practice Address - Phone:310-990-2199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13851103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical