Provider Demographics
NPI:1427842012
Name:PUCCINELLI, SAMUEL RICHARD
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:RICHARD
Last Name:PUCCINELLI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19510 LORAIN RD APT 105
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-1900
Mailing Address - Country:US
Mailing Address - Phone:440-341-4986
Mailing Address - Fax:
Practice Address - Street 1:6700 BETA DR STE 108
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:OH
Practice Address - Zip Code:44143-2335
Practice Address - Country:US
Practice Address - Phone:440-460-0140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health