Healthcare Provider Details

I. General information

NPI: 1184760324
Provider Name (Legal Business Name): ELLA PUCCIO DSW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11020 71 ROAD SUITE 103
FOREST HILLS NY
11375
US

IV. Provider business mailing address

8614 WOODHAVEN BLVD
QUEENS NY
11421
US

V. Phone/Fax

Practice location:
  • Phone: 718-849-5874
  • Fax:
Mailing address:
  • Phone: 718-849-5874
  • Fax: 718-805-1968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR0277201
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: