Healthcare Provider Details

I. General information

NPI: 1437584737
Provider Name (Legal Business Name): THOMAS W PUCKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 S RURAL RD SUITE J
TEMPE AZ
85282-5581
US

IV. Provider business mailing address

3910 S RURAL RD SUITE J
TEMPE AZ
85282-5581
US

V. Phone/Fax

Practice location:
  • Phone: 480-317-9868
  • Fax: 480-317-9867
Mailing address:
  • Phone: 480-317-9868
  • Fax: 480-317-9867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: