=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174006951
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEONARDO CELLA PUCHALVERT CG 60744554
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2018
-----------------------------------------------------
Last Update Date | 09/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 W HARRISON ST STE 109
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98032-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-856-9000
-----------------------------------------------------
Fax | 253-520-6647
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 W HARRISON ST STE 109
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98032-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-856-9000
-----------------------------------------------------
Fax | 253-520-6647
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 60744554
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------