Provider Demographics
NPI:1790494185
Name:BOLSAKOVA, AGNE SOFIA (MA)
Entity Type:Individual
Prefix:
First Name:AGNE
Middle Name:SOFIA
Last Name:BOLSAKOVA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 PIO PICO DR STE 105
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1951
Mailing Address - Country:US
Mailing Address - Phone:760-500-3325
Mailing Address - Fax:
Practice Address - Street 1:2204 S EL CAMINO REAL STE 315
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6390
Practice Address - Country:US
Practice Address - Phone:760-500-3325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11781101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional