MEDICARE: NICHOLAS T. PUCHALSKI LMFT

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	106H00000X	Marriage & Family Therapist
2	106H00000X	Marriage & Family Therapist	15340	AZ

General Provider Information

NPI Number	:	1700255148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS T. PUCHALSKI LMFT

Provider Business Mailing Address
First Line	:	8401 WAYZATA BLVD STE 150
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55426-1343
Country	:	US
Telephone Number	:	763-544-1006
Fax Number	:

Provider Business Practice Location Address
First Line	:	633 E RAY RD STE 131
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85296-4206
Country	:	US
Telephone Number	:	480-256-2829
Fax Number	:

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

Provider Enumeration Date	:	09/16/2015
Last Update Date	:	05/01/2023

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