Healthcare Provider Details

I. General information

NPI: 1609171941
Provider Name (Legal Business Name): MISS SHOSHANA L PUCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 01/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 MICAH DR DRAWER M
OLNEY IL
62450-4720
US

IV. Provider business mailing address

504 MICAH DR DRAWER M
OLNEY IL
62450-4720
US

V. Phone/Fax

Practice location:
  • Phone: 618-395-4306
  • Fax: 618-395-4507
Mailing address:
  • Phone: 618-395-4306
  • Fax: 618-395-4507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: