Healthcare Provider Details

I. General information

NPI: 1578668794
Provider Name (Legal Business Name): MICHAEL TODD PUCKETT LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 N MICHIGAN AVE STE 1400
CHICAGO IL
60611-7500
US

IV. Provider business mailing address

1340 N ASTOR ST APT 2305
CHICAGO IL
60610-2163
US

V. Phone/Fax

Practice location:
  • Phone: 312-214-3588
  • Fax:
Mailing address:
  • Phone: 312-399-6862
  • 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: