Healthcare Provider Details

I. General information

NPI: 1245014414
Provider Name (Legal Business Name): ANNA ELIZABETH PUCCIA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 W MAIN ST
WATERTOWN NY
13601-1381
US

IV. Provider business mailing address

595 W MAIN ST
WATERTOWN NY
13601-1381
US

V. Phone/Fax

Practice location:
  • Phone: 315-788-1530
  • Fax: 315-788-4759
Mailing address:
  • Phone: 315-788-1530
  • Fax: 315-788-4759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number120813
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: