Provider Demographics
NPI:1285867515
Name:PUTT, TRISTA (BA)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:PUTT
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17046-5040
Mailing Address - Country:US
Mailing Address - Phone:717-273-1710
Mailing Address - Fax:717-273-1416
Practice Address - Street 1:938 PENN ST
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19602-1717
Practice Address - Country:US
Practice Address - Phone:610-478-8088
Practice Address - Fax:610-478-4884
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
PAPC007115101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103428968Medicaid