Provider Demographics
NPI:1851463020
Name:VANDENBROUCKE-BOUCKAERT, CHRISTINE M (PHDIN CLINICAL PSY)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:M
Last Name:VANDENBROUCKE-BOUCKAERT
Suffix:
Gender:F
Credentials:PHDIN CLINICAL PSY
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Mailing Address - Street 1:1480 LINCOLN AVE
Mailing Address - Street 2:#12
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2084
Mailing Address - Country:US
Mailing Address - Phone:415-457-5145
Mailing Address - Fax:415-382-9051
Practice Address - Street 1:1480 LINCOLN AVE
Practice Address - Street 2:#12
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2084
Practice Address - Country:US
Practice Address - Phone:415-457-5145
Practice Address - Fax:415-382-9051
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY18851103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL188510Medicare ID - Type Unspecified