Healthcare Provider Details

I. General information

NPI: 1275194482
Provider Name (Legal Business Name): ASHLEY DAWN PUCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14572 US HIGHWAY 23
WAVERLY OH
45690-9373
US

IV. Provider business mailing address

2326 SUGAR RUN RD
PIKETON OH
45661-9718
US

V. Phone/Fax

Practice location:
  • Phone: 740-835-1824
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: