Provider Demographics
NPI:1225115850
Name:PUCKETT, ALISHA (SLP)
Entity Type:Individual
Prefix:MRS
First Name:ALISHA
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MISS
Other - First Name:ALISHA
Other - Middle Name:
Other - Last Name:FABROWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:3325 WILLOWCREEK RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5015
Mailing Address - Country:US
Mailing Address - Phone:219-764-4888
Mailing Address - Fax:219-764-4805
Practice Address - Street 1:3325 WILLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5015
Practice Address - Country:US
Practice Address - Phone:219-764-4888
Practice Address - Fax:219-764-4805
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004379A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist