Healthcare Provider Details

I. General information

NPI: 1689956286
Provider Name (Legal Business Name): MR. PAUL R PUCCINELLI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 AUSTIN AVE
SAN ANSELMO CA
94960-2924
US

IV. Provider business mailing address

15 AUSTIN AVE
SAN ANSELMO CA
94960-2924
US

V. Phone/Fax

Practice location:
  • Phone: 415-342-2839
  • Fax:
Mailing address:
  • Phone: 415-342-2839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: