Provider Demographics
NPI:1952677890
Name:BUCCOLA, BROOKE ANN (PSYD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:ANN
Last Name:BUCCOLA
Suffix:
Gender:F
Credentials:PSYD, LMFT
Other - Prefix:DR
Other - First Name:BROOKE
Other - Middle Name:ANN
Other - Last Name:BUCELLATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT, PSYD
Mailing Address - Street 1:1000 QUAIL ST STE 135
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2719
Mailing Address - Country:US
Mailing Address - Phone:562-650-7207
Mailing Address - Fax:
Practice Address - Street 1:20051 SW BIRCH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1708
Practice Address - Country:US
Practice Address - Phone:562-650-7207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 50417106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist