Basic Information
| Provider Information | |||||||||
| NPI: | 1629005616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUETZER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 138 NORTH COURT STREET MADISON CO. MENTAL HEALTH DEPT | ||||||||
| Address2: | VETERANS MEMORIAL BUILDING | ||||||||
| City: | WAMPSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131630608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153662327 | ||||||||
| FaxNumber: | 3153662599 | ||||||||
| Practice Location | |||||||||
| Address1: | 138 NORTH COURT STREET MADISON CO. MENTAL HEALTH DEPT | ||||||||
| Address2: | VETERANS MEMORIAL BUILDING | ||||||||
| City: | WAMPSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131630608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153662327 | ||||||||
| FaxNumber: | 3153662599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 05/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 071148 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 615530 | 01 | NY | MVP | OTHER |