Provider Demographics
NPI:1760813117
Name:PUCHALSKI, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:PUCHALSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:CAPUTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24445 NORTHWESTERN HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24445 NORTHWESTERN HWY STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2436
Practice Address - Country:US
Practice Address - Phone:248-483-7804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-11
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI7401000989103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other