Healthcare Provider Details

I. General information

NPI: 1518426949
Provider Name (Legal Business Name): STEPHANIE M PUCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 03/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 CANTERBURY RD
RALEIGH NC
27608-1900
US

IV. Provider business mailing address

1206 CANTERBURY RD
RALEIGH NC
27608-1900
US

V. Phone/Fax

Practice location:
  • Phone: 919-622-5906
  • Fax:
Mailing address:
  • Phone: 919-622-5906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA14640
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: