Healthcare Provider Details

I. General information

NPI: 1174006951
Provider Name (Legal Business Name): LEONARDO CELLA PUCHALVERT CG 60744554
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 W HARRISON ST STE 109
KENT WA
98032-4403
US

IV. Provider business mailing address

515 W HARRISON ST STE 109
KENT WA
98032-4403
US

V. Phone/Fax

Practice location:
  • Phone: 253-856-9000
  • Fax: 253-520-6647
Mailing address:
  • Phone: 253-856-9000
  • Fax: 253-520-6647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number60744554
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: