Provider Demographics
NPI:1750651139
Name:PUCKETT, KOREY J (LICSW)
Entity type:Individual
Prefix:
First Name:KOREY
Middle Name:J
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5815 COMSTOCK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-2214
Mailing Address - Country:US
Mailing Address - Phone:410-236-0028
Mailing Address - Fax:
Practice Address - Street 1:1629 K ST NW
Practice Address - Street 2:SUITE 300
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-1602
Practice Address - Country:US
Practice Address - Phone:410-236-0028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500792471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical