Provider Demographics
NPI:1750108718
Name:PUCKETT, SAMANTHA (OTR/L)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 MEADOWBROOK MALL CT STE 22
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8775
Mailing Address - Country:US
Mailing Address - Phone:336-778-0292
Mailing Address - Fax:
Practice Address - Street 1:6000 MEADOWBROOK MALL CT STE 22
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8775
Practice Address - Country:US
Practice Address - Phone:336-778-0292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17091225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist