Healthcare Provider Details

I. General information

NPI: 1649642042
Provider Name (Legal Business Name): SUSANA BEATRIZ PURICELLI M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2015
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30209 21ST AVE S
FEDERAL WAY WA
98003-4249
US

IV. Provider business mailing address

30209 21ST AVE S
FEDERAL WAY WA
98003-4249
US

V. Phone/Fax

Practice location:
  • Phone: 206-850-7584
  • Fax:
Mailing address:
  • Phone: 206-850-7584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCL 60163927
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60804720
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: