Provider Demographics
NPI:1881811834
Name:PUCCIO, SUSAN LEE (MHC)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LEE
Last Name:PUCCIO
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5516 GOVERNORS DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7810
Mailing Address - Country:US
Mailing Address - Phone:239-433-1248
Mailing Address - Fax:
Practice Address - Street 1:3900 BROADWAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8193
Practice Address - Country:US
Practice Address - Phone:239-939-2808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 6084101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health