MEDICARE: KATHLEEN PUCHALSKI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1316141088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN PUCHALSKI

Provider Business Mailing Address
First Line	:	PO BOX 167
Second Line	:
City	:	SWINK
State	:	OK
Zip	:	74761-0167
Country	:	US
Telephone Number	:	580-873-9431
Fax Number	:

Provider Business Practice Location Address
First Line	:	4240 EAST 2080 RD
Second Line	:
City	:	FORT TOWSON
State	:	OK
Zip	:	74735
Country	:	US
Telephone Number	:	580-873-9431
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2007
Last Update Date	:	03/27/2012

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