Provider Demographics
NPI:1578668794
Name:PUCKETT, MICHAEL TODD (LCPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TODD
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 N ASTOR ST APT 2305
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2163
Mailing Address - Country:US
Mailing Address - Phone:312-399-6862
Mailing Address - Fax:
Practice Address - Street 1:980 N MICHIGAN AVE STE 1400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-7500
Practice Address - Country:US
Practice Address - Phone:312-214-3588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health