Healthcare Provider Details

I. General information

NPI: 1568677037
Provider Name (Legal Business Name): MARCY S PUKLIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 PLAINS RD
MILFORD CT
06461-2573
US

IV. Provider business mailing address

1 VICTORIA LN
WESTPORT CT
06880-2155
US

V. Phone/Fax

Practice location:
  • Phone: 203-858-5560
  • Fax:
Mailing address:
  • Phone: 203-227-5752
  • Fax: 203-221-8119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002528
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: