Provider Demographics
NPI:1033683867
Name:PUCKETT, SANDRA (LPC, LBS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:LPC, LBS
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 26510
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-0510
Mailing Address - Country:US
Mailing Address - Phone:484-501-4836
Mailing Address - Fax:
Practice Address - Street 1:296 W RIDGE PIKE # LL102
Practice Address - Street 2:
Practice Address - City:ROYERSFORD
Practice Address - State:PA
Practice Address - Zip Code:19468-1790
Practice Address - Country:US
Practice Address - Phone:484-501-4836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC016885101YP2500X
PABH005638103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional