Provider Demographics
NPI:1720155823
Name:PUTZ, BRIAN WILLIAM (MA, LP)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:WILLIAM
Last Name:PUTZ
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15873 CRANE ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6200 SHINGLE CREEK PKWY STE 455
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2178
Practice Address - Country:US
Practice Address - Phone:763-503-8560
Practice Address - Fax:763-503-8563
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3322103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN657T1PUOtherBCBS MN
MNHP31888OtherHEALTH PARTNERS
MN1021025OtherCIGNA
MN62-50561OtherMEDICA UBH
MN990991031581OtherBHP PREFERRED 1
MN141966OtherU CARE