Provider Demographics
NPI:1770803322
Name:PUTNAM, CLARALICE (MED, LPC)
Entity type:Individual
Prefix:MS
First Name:CLARALICE
Middle Name:
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-7115
Mailing Address - Country:US
Mailing Address - Phone:580-310-4750
Mailing Address - Fax:580-559-2223
Practice Address - Street 1:124 S BROADWAY AVE
Practice Address - Street 2:AMERICAN BUILDING-SUITE 406
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-5820
Practice Address - Country:US
Practice Address - Phone:580-310-4750
Practice Address - Fax:580-559-2223
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-06
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2311101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200051000 BMedicaid