Provider Demographics
NPI:1144243551
Name:PUTTLER-MILLER, KRISTINA DIANE (MSW,LCSW,QMHP)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:DIANE
Last Name:PUTTLER-MILLER
Suffix:
Gender:F
Credentials:MSW,LCSW,QMHP
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:DIANE
Other - Last Name:PUTTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1720 SW WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-4722
Mailing Address - Country:US
Mailing Address - Phone:503-644-0655
Mailing Address - Fax:
Practice Address - Street 1:14195 SW MILLIKAN WAY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2307
Practice Address - Country:US
Practice Address - Phone:503-644-2545
Practice Address - Fax:503-644-0379
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORL28691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR131504Medicare ID - Type Unspecified