Provider Demographics
NPI:1932967247
Name:PUCKETT, RICHARD TERRENCE LEE JR (N/A)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:TERRENCE LEE
Last Name:PUCKETT
Suffix:JR
Gender:M
Credentials:N/A
Other - Prefix:MR
Other - First Name:LEE
Other - Middle Name:TERRENCE
Other - Last Name:PUCKETT
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:N/A
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:DILLINGHAM
Mailing Address - State:AK
Mailing Address - Zip Code:99576-0638
Mailing Address - Country:US
Mailing Address - Phone:907-843-1191
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:533 CENTRAL AVENUE
Practice Address - Street 2:638
Practice Address - City:DILLINGHAM
Practice Address - State:AK
Practice Address - Zip Code:99576
Practice Address - Country:US
Practice Address - Phone:907-843-1191
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YA0400X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)