Provider Demographics
NPI:1851669972
Name:PUCKETT COUNSELING SERVICES
Entity Type:Organization
Organization Name:PUCKETT COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH-PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:270-629-6373
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:270-629-6373
Mailing Address - Fax:270-479-1302
Practice Address - Street 1:220 N RACE ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-2816
Practice Address - Country:US
Practice Address - Phone:270-629-6373
Practice Address - Fax:270-479-1302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-03
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X
KY0615106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100276850Medicaid