Provider Demographics
NPI:1689956286
Name:PUCCINELLI, PAUL R
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:R
Last Name:PUCCINELLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2924
Mailing Address - Country:US
Mailing Address - Phone:415-342-2839
Mailing Address - Fax:
Practice Address - Street 1:15 AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2924
Practice Address - Country:US
Practice Address - Phone:415-342-2839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist