Provider Demographics
NPI:1134323322
Name:PRISCILLA PUTNAM, PH.D., LLC
Entity Type:Organization
Organization Name:PRISCILLA PUTNAM, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:PUTNAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:302-454-8010
Mailing Address - Street 1:168 S. MAIN ST.
Mailing Address - Street 2:SUITE 208
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-7933
Mailing Address - Country:US
Mailing Address - Phone:302-454-8010
Mailing Address - Fax:302-454-8026
Practice Address - Street 1:168 S. MAIN ST.
Practice Address - Street 2:SUITE 208
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-7933
Practice Address - Country:US
Practice Address - Phone:302-454-8010
Practice Address - Fax:302-454-8026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB10000472103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEDF6995OtherPALMETTO GBA-RAILROAD MED
DEG02525Medicare PIN