Healthcare Provider Details

I. General information

NPI: 1104563360
Provider Name (Legal Business Name): MERANDA PUCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 GROVEPORT RD
GROVEPORT OH
43125-1005
US

IV. Provider business mailing address

211 S 5TH ST
COLUMBUS OH
43215-5203
US

V. Phone/Fax

Practice location:
  • Phone: 614-567-6274
  • Fax: 855-604-0927
Mailing address:
  • Phone: 614-567-6274
  • Fax: 855-604-0927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.184779
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: