Provider Demographics
NPI:1497855175
Name:PUTNAM, PRISCILLA H (PHD)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:H
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 S. MAIN ST.
Mailing Address - Street 2:SUITE 208
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-3841
Mailing Address - Country:US
Mailing Address - Phone:302-454-8010
Mailing Address - Fax:302-454-8026
Practice Address - Street 1:168 S. MAIN ST.
Practice Address - Street 2:SUITE 208
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-7962
Practice Address - Country:US
Practice Address - Phone:302-454-8010
Practice Address - Fax:302-454-8026
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB1-0000472103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEDF6995OtherPALMETTO GBA-RAILROAD MED
DEDF6995OtherPALMETTO GBA-RAILROAD MED