Provider Demographics
NPI:1932327509
Name:PUCKETT, SHELIA JANE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHELIA
Middle Name:JANE
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 E BROADWAY BLVD
Mailing Address - Street 2:SUITE 124-143
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-5966
Mailing Address - Country:US
Mailing Address - Phone:520-232-2021
Mailing Address - Fax:520-232-2553
Practice Address - Street 1:5240 E PIMA ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-3630
Practice Address - Country:US
Practice Address - Phone:520-232-2021
Practice Address - Fax:520-232-2553
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2502235Z00000X
AZSLP 7976235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ766934Medicaid