Healthcare Provider Details

I. General information

NPI: 1174453732
Provider Name (Legal Business Name): MR. RYAN PUCKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 W BELMONT AVE
CHICAGO IL
60657-4408
US

IV. Provider business mailing address

711 W BROMPTON AVE APT 46
CHICAGO IL
60657-1884
US

V. Phone/Fax

Practice location:
  • Phone: 312-530-0323
  • Fax:
Mailing address:
  • Phone: 312-530-0323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: