Provider Demographics
NPI:1568677037
Name:PUKLIN, MARCY S (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARCY
Middle Name:S
Last Name:PUKLIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VICTORIA LN
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-2155
Mailing Address - Country:US
Mailing Address - Phone:203-227-5752
Mailing Address - Fax:203-221-8119
Practice Address - Street 1:57 PLAINS RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06461-2573
Practice Address - Country:US
Practice Address - Phone:203-858-5560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0025281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002528OtherSTATE LICENSE
CT80000666Medicare ID - Type Unspecified