Provider Demographics
NPI:1215537121
Name:PUCHKAREV, DMITRIY VICTOR (ASW)
Entity type:Individual
Prefix:MR
First Name:DMITRIY
Middle Name:VICTOR
Last Name:PUCHKAREV
Suffix:
Gender:
Credentials:ASW
Other - Prefix:
Other - First Name:DIMA
Other - Middle Name:
Other - Last Name:PUCHKAREV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10943 NATIONAL BLVD APT 6
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-4052
Mailing Address - Country:US
Mailing Address - Phone:858-213-9391
Mailing Address - Fax:
Practice Address - Street 1:503 OCEAN FRONT WALK
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2403
Practice Address - Country:US
Practice Address - Phone:310-392-3070
Practice Address - Fax:310-452-8766
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1272351041C0700X
390200000X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program