Provider Demographics
NPI:1013491356
Name:HURGE-PUTNAM, LYSETTA B (LICSW)
Entity Type:Individual
Prefix:
First Name:LYSETTA
Middle Name:B
Last Name:HURGE-PUTNAM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 DUNDEE CIR
Mailing Address - Street 2:
Mailing Address - City:HARWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02645-3388
Mailing Address - Country:US
Mailing Address - Phone:774-408-0344
Mailing Address - Fax:
Practice Address - Street 1:33 DUNDEE CIR
Practice Address - Street 2:
Practice Address - City:HARWICH
Practice Address - State:MA
Practice Address - Zip Code:02645-3388
Practice Address - Country:US
Practice Address - Phone:774-408-0344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-22
Last Update Date:2018-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1079911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical