Provider Demographics
NPI:1003335100
Name:PUCKETT, ALYSHA JEAN (BA, QMHS)
Entity Type:Individual
Prefix:MS
First Name:ALYSHA
Middle Name:JEAN
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:BA, QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT ORAB
Mailing Address - State:OH
Mailing Address - Zip Code:45154-8349
Mailing Address - Country:US
Mailing Address - Phone:937-444-1613
Mailing Address - Fax:
Practice Address - Street 1:710 N HIGH ST
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154-8349
Practice Address - Country:US
Practice Address - Phone:937-444-1613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator