Provider Demographics
NPI:1790142875
Name:BOUCK, VIKKI (LCSW)
Entity Type:Individual
Prefix:
First Name:VIKKI
Middle Name:
Last Name:BOUCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3665 AVOCADO VILLAGE CT
Mailing Address - Street 2:UNIT 165
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7375
Mailing Address - Country:US
Mailing Address - Phone:619-665-4142
Mailing Address - Fax:
Practice Address - Street 1:3665 AVOCADO VILLAGE CT
Practice Address - Street 2:UNIT 165
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7375
Practice Address - Country:US
Practice Address - Phone:619-665-4142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23706101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health