Healthcare Provider Details

I. General information

NPI: 1881207496
Provider Name (Legal Business Name): KEVIN RYAN PUCKETT I LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 FIVE POINTS RD SW
ALBUQUERQUE NM
87105-3179
US

IV. Provider business mailing address

1805 LLANO CT NW
ALBUQUERQUE NM
87107-2631
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-6919
  • Fax:
Mailing address:
  • Phone: 505-506-7595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberCSA0210841
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: