Provider Demographics
NPI:1346648441
Name:PUTNAM, ASHLEY (ATC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 ELMWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1424
Mailing Address - Country:US
Mailing Address - Phone:814-450-3340
Mailing Address - Fax:
Practice Address - Street 1:6525 2ND AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3006
Practice Address - Country:US
Practice Address - Phone:313-970-8417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-05
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0045722255A2300X
MI26010013602255A2300X
HI752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer