Healthcare Provider Details

I. General information

NPI: 1669820833
Provider Name (Legal Business Name): GABRIELLE PUCCINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2016
Last Update Date: 05/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 HOLLYWOOD BLVD
HOLLYWOOD FL
33021-6795
US

IV. Provider business mailing address

3911 HOLLYWOOD BLVD
HOLLYWOOD FL
33021-6795
US

V. Phone/Fax

Practice location:
  • Phone: 954-639-7345
  • Fax:
Mailing address:
  • Phone: 954-639-7345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMT2418
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: