Healthcare Provider Details

I. General information

NPI: 1649234964
Provider Name (Legal Business Name): GRACE PUCHALSKI LCSW-
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 OLD LIVERPOOL RD SUITE K
LIVERPOOL NY
13088-5757
US

IV. Provider business mailing address

203 SUNFLOWER DR
LIVERPOOL NY
13088-5646
US

V. Phone/Fax

Practice location:
  • Phone: 315-278-4523
  • Fax:
Mailing address:
  • Phone: 315-278-4523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR046862
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: