Provider Demographics
NPI:1316433774
Name:PUCKETT, VIRGINIA LOUISE (LPC)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:LOUISE
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8304 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-6935
Mailing Address - Country:US
Mailing Address - Phone:678-838-9336
Mailing Address - Fax:678-838-3619
Practice Address - Street 1:8304 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134
Practice Address - Country:US
Practice Address - Phone:678-838-9336
Practice Address - Fax:678-838-3619
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC005224101YP2500X
GALPC011970101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA83-1265587Medicaid