Provider Demographics
NPI:1316586001
Name:PUCKETT, CRISTINA (LCSW)
Entity Type:Individual
Prefix:
First Name:CRISTINA
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:LCSW
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 20512
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71903-0512
Mailing Address - Country:US
Mailing Address - Phone:501-463-0209
Mailing Address - Fax:
Practice Address - Street 1:1401 MALVERN AVE STE 152
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-6370
Practice Address - Country:US
Practice Address - Phone:501-463-0209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR9805-M104100000X
AR9805-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR289620719Medicaid