Provider Demographics
NPI:1306597794
Name:PUCKETT, MADELEINE JUSTINE (LCSWA)
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:JUSTINE
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 OAK BRANCH DR STE H
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-2157
Mailing Address - Country:US
Mailing Address - Phone:336-288-9190
Mailing Address - Fax:
Practice Address - Street 1:5 OAK BRANCH DR STE H
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-2157
Practice Address - Country:US
Practice Address - Phone:336-288-9190
Practice Address - Fax:336-450-4318
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NCP0183421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker