Provider Demographics
NPI:1215187000
Name:PUTNAM, MARIE HAZEL
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:HAZEL
Last Name:PUTNAM
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 1:70 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2033
Mailing Address - Country:US
Mailing Address - Phone:248-338-7458
Mailing Address - Fax:248-338-7513
Practice Address - Street 1:303 W WATER ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5627
Practice Address - Country:US
Practice Address - Phone:810-253-3888
Practice Address - Fax:810-496-8539
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801085566101YM0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health