Provider Demographics
NPI:1518943133
Name:PUCKETT, PEGGY SMITH (LMFT)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:SMITH
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 WILLIE GROCE RD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-7831
Mailing Address - Country:US
Mailing Address - Phone:270-791-2178
Mailing Address - Fax:270-710-1794
Practice Address - Street 1:2130 WILLIE GROCE RD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-7831
Practice Address - Country:US
Practice Address - Phone:270-791-2178
Practice Address - Fax:270-710-1794
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0615106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100059670Medicaid
KY11508376OtherCAQH ID
KY7100059630Medicaid
KY000000537338OtherANTHEM BLUE CROSS/BLUE SH