Provider Demographics
NPI:1023564580
Name:MARTA PUCHALLA, LMFT, PC
Entity Type:Organization
Organization Name:MARTA PUCHALLA, LMFT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTA
Authorized Official - Middle Name:
Authorized Official - Last Name:PUCHALLA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:719-205-1865
Mailing Address - Street 1:1751 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-1926
Mailing Address - Country:US
Mailing Address - Phone:719-471-1816
Mailing Address - Fax:719-471-9987
Practice Address - Street 1:1751 S 8TH ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1926
Practice Address - Country:US
Practice Address - Phone:719-471-1816
Practice Address - Fax:719-471-9987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMFT0000378106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO106455Medicaid