Provider Demographics
NPI:1184760324
Name:PUCCIO, ELLA (DSW LCSW)
Entity type:Individual
Prefix:
First Name:ELLA
Middle Name:
Last Name:PUCCIO
Suffix:
Gender:F
Credentials:DSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 WOODHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS
Mailing Address - State:NY
Mailing Address - Zip Code:11421
Mailing Address - Country:US
Mailing Address - Phone:718-849-5874
Mailing Address - Fax:718-805-1968
Practice Address - Street 1:11020 71 ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:718-849-5874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR02772011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY81546Medicare ID - Type Unspecified
R28207Medicare UPIN