Healthcare Provider Details

I. General information

NPI: 1831299205
Provider Name (Legal Business Name): DIANE PUCKETT LPC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9675-A MAIN STREET
FAIRFAX VA
22031
US

IV. Provider business mailing address

9618 DUBLIN DRIVE
MANASSAS VA
20109-3356
US

V. Phone/Fax

Practice location:
  • Phone: 703-405-2582
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701002623
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: