Provider Demographics
NPI:1326560020
Name:PUTNAM, THOMAS J (LCSW)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:PUTNAM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8815 TRADEWIND RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-7021
Mailing Address - Country:US
Mailing Address - Phone:505-604-1244
Mailing Address - Fax:
Practice Address - Street 1:8815 TRADEWIND RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-7021
Practice Address - Country:US
Practice Address - Phone:505-604-1244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-111691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM82485747Medicaid