Provider Demographics
NPI:1023849692
Name:PUCCIO, CRYSTAL (LMSW)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:PUCCIO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10329 LOS ARBOLES AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1518
Mailing Address - Country:US
Mailing Address - Phone:505-435-4152
Mailing Address - Fax:
Practice Address - Street 1:5400 GIBSON BLVD SE STE 3
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5181
Practice Address - Country:US
Practice Address - Phone:505-254-4564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2022-0883104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker