Provider Demographics
NPI:1306005228
Name:PUTNAM, AMY ELIZABETH (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:ELIZABETH
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 BAXTER BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-1823
Mailing Address - Country:US
Mailing Address - Phone:207-874-1065
Mailing Address - Fax:207-874-1068
Practice Address - Street 1:43 BAXTER BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1823
Practice Address - Country:US
Practice Address - Phone:207-874-1065
Practice Address - Fax:207-874-1068
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEST 1771235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432670399Medicaid