Healthcare Provider Details

I. General information

NPI: 1790373991
Provider Name (Legal Business Name): MR. ANTHONY DEAN PUCKET
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105C W WALL ST
HARRISONVILLE MO
64701-2355
US

IV. Provider business mailing address

12031 HEMLOCK ST
OVERLAND PARK KS
66213-1251
US

V. Phone/Fax

Practice location:
  • Phone: 816-974-7378
  • Fax:
Mailing address:
  • Phone: 913-481-2089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberT-LMFT3156
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: