Healthcare Provider Details

I. General information

NPI: 1124752498
Provider Name (Legal Business Name): ELENA MARIE PUCHI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2022
Last Update Date: 07/13/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 DULANEY VALLEY RD
TIMONIUM MD
21093-2700
US

IV. Provider business mailing address

4510 E BANNER GATEWAY DR APT 1070
MESA AZ
85206-4751
US

V. Phone/Fax

Practice location:
  • Phone: 410-252-4500
  • Fax:
Mailing address:
  • Phone: 410-210-9880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberA02171
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: