Provider Demographics
NPI:1992477749
Name:PUCKETT, BRENDA KAY
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5736 FORSYTHIA CT
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41015-4223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11438 LEBANON RD UNIT H
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45241-6201
Practice Address - Country:US
Practice Address - Phone:513-216-4181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2103142101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional