Provider Demographics
NPI:1174006951
Name:CELLA PUCHALVERT, LEONARDO (CG 60744554)
Entity Type:Individual
Prefix:
First Name:LEONARDO
Middle Name:
Last Name:CELLA PUCHALVERT
Suffix:
Gender:M
Credentials:CG 60744554
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W HARRISON ST STE 109
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-4403
Mailing Address - Country:US
Mailing Address - Phone:253-856-9000
Mailing Address - Fax:253-520-6647
Practice Address - Street 1:515 W HARRISON ST STE 109
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-4403
Practice Address - Country:US
Practice Address - Phone:253-856-9000
Practice Address - Fax:253-520-6647
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60744554103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling