Provider Demographics
NPI:1750699591
Name:BUKSA, KIMBERLY KAY (MA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:BUKSA
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 1:314 BOND AVE
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5647
Mailing Address - Country:US
Mailing Address - Phone:415-623-9514
Mailing Address - Fax:
Practice Address - Street 1:5 KELLER ST
Practice Address - Street 2:SUITE D
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2349
Practice Address - Country:US
Practice Address - Phone:707-776-6414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92609106H00000X
CA59864106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist