Provider Demographics
NPI:1225203656
Name:PUCEL, JOHN CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHARLES
Last Name:PUCEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 25TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-9500
Mailing Address - Country:US
Mailing Address - Phone:320-253-5405
Mailing Address - Fax:320-203-8387
Practice Address - Street 1:1481 25TH ST SE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-9500
Practice Address - Country:US
Practice Address - Phone:320-253-5405
Practice Address - Fax:320-203-8387
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-27
Last Update Date:2008-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2005103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical