Provider Demographics
NPI:1891547907
Name:PUTNAM, ELLIE JEAN
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:JEAN
Last Name:PUTNAM
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 1:17 ARBOR CT
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:NE
Mailing Address - Zip Code:68467-1535
Mailing Address - Country:US
Mailing Address - Phone:402-366-0047
Mailing Address - Fax:
Practice Address - Street 1:14301 FNB PKWY
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-7200
Practice Address - Country:US
Practice Address - Phone:402-807-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician