Provider Demographics
NPI:1790242212
Name:PUTNAM, ELIZABETH RUSSO (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RUSSO
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901
Mailing Address - Country:US
Mailing Address - Phone:201-572-6237
Mailing Address - Fax:
Practice Address - Street 1:88 MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901
Practice Address - Country:US
Practice Address - Phone:201-572-6237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00378100225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation