Healthcare Provider Details

I. General information

NPI: 1164255451
Provider Name (Legal Business Name): TINA PUCKETT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N WATER ST
KENT OH
44240-2418
US

IV. Provider business mailing address

155 N WATER ST
KENT OH
44240-2418
US

V. Phone/Fax

Practice location:
  • Phone: 330-678-3006
  • Fax:
Mailing address:
  • Phone: 330-678-3006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2405894-TRNE
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2507111
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: