Provider Demographics
NPI:1891242236
Name:PUCKETT, ROBERT (MFT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 SE 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3905
Mailing Address - Country:US
Mailing Address - Phone:323-217-3460
Mailing Address - Fax:
Practice Address - Street 1:2302 SE SALMON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3944
Practice Address - Country:US
Practice Address - Phone:323-217-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70245106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist