Healthcare Provider Details

I. General information

NPI: 1881811834
Provider Name (Legal Business Name): SUSAN LEE PUCCIO MHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 BROADWAY
FORT MYERS FL
33901-8193
US

IV. Provider business mailing address

5516 GOVERNORS DR
FORT MYERS FL
33907-7810
US

V. Phone/Fax

Practice location:
  • Phone: 239-939-2808
  • Fax:
Mailing address:
  • Phone: 239-433-1248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH 6084
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: