Healthcare Provider Details

I. General information

NPI: 1386934107
Provider Name (Legal Business Name): THERESA PUCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 DEERING AVE
PORTLAND ME
04102-2901
US

IV. Provider business mailing address

92 DEERING AVE
PORTLAND ME
04102-2901
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-8104
  • Fax: 207-874-8290
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLM1043
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: