Provider Demographics
NPI:1114563996
Name:BRUASKI, LAUREN VICTORIA
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:VICTORIA
Last Name:BRUASKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4647 PICO ST APT 104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-3844
Mailing Address - Country:US
Mailing Address - Phone:714-337-4969
Mailing Address - Fax:
Practice Address - Street 1:3130 FIFTH AVE STE 8
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5839
Practice Address - Country:US
Practice Address - Phone:714-337-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT115030106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist