Healthcare Provider Details

I. General information

NPI: 1952056970
Provider Name (Legal Business Name): KELLY PUCKETT LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 COURT ST STE 1303
BROOKLYN NY
11242-1113
US

IV. Provider business mailing address

613 18TH ST APT 2F
BROOKLYN NY
11218-1130
US

V. Phone/Fax

Practice location:
  • Phone: 502-592-0602
  • Fax:
Mailing address:
  • Phone: 502-592-0602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number108240-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: