Provider Demographics
NPI:1104584150
Name:PUCKETT, TAYLOR JADE (BCBA)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:JADE
Last Name:PUCKETT
Suffix:
Gender:
Credentials:BCBA
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:JADE
Other - Last Name:STALBIRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:140 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-3442
Mailing Address - Country:US
Mailing Address - Phone:607-377-9647
Mailing Address - Fax:
Practice Address - Street 1:8001 BEATY GROVE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1602
Practice Address - Country:US
Practice Address - Phone:813-926-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11831948103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst