Provider Demographics
NPI:1881193175
Name:PUCKETT, ROBIN LYNN (MAPC LAC)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:LYNN
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:MAPC LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5836
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85376-5836
Mailing Address - Country:US
Mailing Address - Phone:623-694-0866
Mailing Address - Fax:623-975-2083
Practice Address - Street 1:17505 N 79TH AVE STE 311G
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8730
Practice Address - Country:US
Practice Address - Phone:623-876-2029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC12884101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor