Provider Demographics
NPI:1770841538
Name:PUCCIO, LAURA ANN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:PUCCIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3316
Mailing Address - Country:US
Mailing Address - Phone:917-974-3000
Mailing Address - Fax:212-898-1143
Practice Address - Street 1:104 W 29TH ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5310
Practice Address - Country:US
Practice Address - Phone:212-616-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool