Provider Demographics
NPI:1952056970
Name:PUCKETT, KELLY (LMSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 18TH ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1130
Mailing Address - Country:US
Mailing Address - Phone:502-592-0602
Mailing Address - Fax:
Practice Address - Street 1:26 COURT ST STE 1303
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11242-1113
Practice Address - Country:US
Practice Address - Phone:502-592-0602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108240-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical