Provider Demographics
NPI:1780005405
Name:BOEGEL, BIANCA
Entity Type:Individual
Prefix:MS
First Name:BIANCA
Middle Name:
Last Name:BOEGEL
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 1:299 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-6003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:299 12TH ST
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933
Practice Address - Country:US
Practice Address - Phone:831-647-7633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-23
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA104799106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor