Provider Demographics
NPI:1821634148
Name:PUTMAN, MARIA MICHELLE
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:MICHELLE
Last Name:PUTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12800 E WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2061
Mailing Address - Country:US
Mailing Address - Phone:313-308-1400
Mailing Address - Fax:313-824-5589
Practice Address - Street 1:1260 WOODBRIDGE ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1621
Practice Address - Country:US
Practice Address - Phone:586-350-1778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016969101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health