Provider Demographics
NPI:1669072401
Name:PUCKETT, KIMBER
Entity type:Individual
Prefix:
First Name:KIMBER
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 TOWER DR STE A
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5045
Mailing Address - Country:US
Mailing Address - Phone:318-237-2440
Mailing Address - Fax:
Practice Address - Street 1:2101 TOWER DR STE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5045
Practice Address - Country:US
Practice Address - Phone:318-237-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1679507412OtherNPI
LA1544761Medicaid