Provider Demographics
NPI:1881207496
Name:PUCKETT, KEVIN RYAN I (LSAA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RYAN
Last Name:PUCKETT
Suffix:I
Gender:M
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 LLANO CT NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-2631
Mailing Address - Country:US
Mailing Address - Phone:505-506-7595
Mailing Address - Fax:
Practice Address - Street 1:1528 FIVE POINTS RD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-3179
Practice Address - Country:US
Practice Address - Phone:505-242-6919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0210841103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)