Provider Demographics
NPI:1104497973
Name:PUCKETT, SADA KATHRYN (LPCC, LADC)
Entity type:Individual
Prefix:
First Name:SADA
Middle Name:KATHRYN
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:LPCC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 ANNAPOLIS LN N STE 130
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-3632
Mailing Address - Country:US
Mailing Address - Phone:763-220-0218
Mailing Address - Fax:
Practice Address - Street 1:2415 ANNAPOLIS LN N STE 130
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3632
Practice Address - Country:US
Practice Address - Phone:763-220-0218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304393101YA0400X
MN02663101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)