Provider Demographics
NPI:1639275761
Name:PUCKETT, RICHARD (LPMED)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:LPMED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 EMERALD DR
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-5060
Mailing Address - Country:US
Mailing Address - Phone:218-327-9013
Mailing Address - Fax:218-327-9013
Practice Address - Street 1:2618 EMERALD DR
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-5060
Practice Address - Country:US
Practice Address - Phone:218-327-9013
Practice Address - Fax:218-327-9013
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1835103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN223G6PUOtherBLUE CROSS BLUE SHIELD MN
MN6254190OtherMEDICA