MEDICARE: WALK WITH GRACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R046862	NY

General Provider Information

NPI Number	:	1336519172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALK WITH GRACE

Provider Business Mailing Address
First Line	:	PO BOX 880
Second Line	:
City	:	CENTRAL SQUARE
State	:	NY
Zip	:	13036-0880
Country	:	US
Telephone Number	:	313-278-4523
Fax Number	:

Provider Business Practice Location Address
First Line	:	435 S MAIN ST
Second Line	:	TEMPORARY ADDRESS
City	:	N SYRACUSE
State	:	NY
Zip	:	13212-2811
Country	:	US
Telephone Number	:	315-278-4523
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GRACE PUCHALSKI
Credential	:	LCSW-R
Telephone Number	:	315-278-4523

Provider Enumeration Date	:	10/06/2015
Last Update Date	:	10/06/2015

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Directions to “WALK WITH GRACE ” Practice Location

Language	Start Address	Practice Location

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