Healthcare Provider Details

I. General information

NPI: 1033683867
Provider Name (Legal Business Name): SANDRA L. PUCKETT LPC, LBS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 07/22/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 SKIPPACK PIKE SUITE B4
SKIPPACK PA
19474
US

IV. Provider business mailing address

PO BOX 26510
COLLEGEVILLE PA
19426
US

V. Phone/Fax

Practice location:
  • Phone: 484-501-4836
  • Fax:
Mailing address:
  • Phone: 484-501-4836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBH005638
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC016885
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: