Provider Demographics
NPI:1033479068
Name:PUTELIS, ELIZABETH ANN
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:PUTELIS
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 1:105 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501-1103
Mailing Address - Country:US
Mailing Address - Phone:508-981-1930
Mailing Address - Fax:
Practice Address - Street 1:330 SW CUTOFF STE 203
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-2730
Practice Address - Country:US
Practice Address - Phone:508-341-2829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-24
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA2047103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA042611055OtherTAX ID
MAM18633OtherBCBS
MA1303287Medicaid
MA99618201OtherNETWORK HEALTH
MA1004745OtherNHP
MA1303287OtherMBHP
MA0000023532OtherBMC