Provider Demographics
NPI:1316141088
Name:PUCHALSKI, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:PUCHALSKI
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:PO BOX 167
Mailing Address - Street 2:
Mailing Address - City:SWINK
Mailing Address - State:OK
Mailing Address - Zip Code:74761-0167
Mailing Address - Country:US
Mailing Address - Phone:580-873-9431
Mailing Address - Fax:
Practice Address - Street 1:4240 EAST 2080 RD
Practice Address - Street 2:
Practice Address - City:FORT TOWSON
Practice Address - State:OK
Practice Address - Zip Code:74735
Practice Address - Country:US
Practice Address - Phone:580-873-9431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical