Provider Demographics
NPI:1770982308
Name:PUCKETT, ELIZABETH (MA, EDS)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:MA, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 SLATE RUN DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-7902
Mailing Address - Country:US
Mailing Address - Phone:614-226-5792
Mailing Address - Fax:
Practice Address - Street 1:407 SLATE RUN DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-7902
Practice Address - Country:US
Practice Address - Phone:614-226-5792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3129742103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool