Provider Demographics
NPI:1447559414
Name:PUCKETT, MEGAN R
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:R
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:R
Other - Last Name:STROBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 S EDWIN C MOSES BLVD
Mailing Address - Street 2:FOURTH FLOOR NW BUILDING
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3424
Mailing Address - Country:US
Mailing Address - Phone:937-276-8333
Mailing Address - Fax:937-276-8339
Practice Address - Street 1:601 S EDWIN C MOSES BLVD
Practice Address - Street 2:FOURTH FLOOR NW BUILDING
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3424
Practice Address - Country:US
Practice Address - Phone:937-276-8333
Practice Address - Fax:937-276-8339
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0900476101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health