Provider Demographics
NPI:1740786706
Name:PUCKETT, TRACEY LEE SR (CDCA, QMHS, BA)
Entity Type:Individual
Prefix:MR
First Name:TRACEY
Middle Name:LEE
Last Name:PUCKETT
Suffix:SR
Gender:M
Credentials:CDCA, QMHS, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 DEAN LN
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:OH
Mailing Address - Zip Code:45628-9626
Mailing Address - Country:US
Mailing Address - Phone:740-981-7546
Mailing Address - Fax:
Practice Address - Street 1:899 E BROAD ST # 110
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1156
Practice Address - Country:US
Practice Address - Phone:614-220-8655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH130994101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)