Provider Demographics
NPI:1851904239
Name:BRUCHSTEIN, DALIT (LICENSED MFT)
Entity Type:Individual
Prefix:
First Name:DALIT
Middle Name:
Last Name:BRUCHSTEIN
Suffix:
Gender:F
Credentials:LICENSED MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 STANLEY AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-3934
Mailing Address - Country:US
Mailing Address - Phone:714-642-7057
Mailing Address - Fax:
Practice Address - Street 1:18542 VANDERLIP AVE STE B
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8201
Practice Address - Country:US
Practice Address - Phone:714-642-7057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MFC45793102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC45793OtherBBS LICENCE