Healthcare Provider Details

I. General information

NPI: 1417322421
Provider Name (Legal Business Name): SAMANTHA DIANE PUTNAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W 6TH ST
CHICO CA
95928-5508
US

IV. Provider business mailing address

130 W 6TH ST
CHICO CA
95928-5508
US

V. Phone/Fax

Practice location:
  • Phone: 530-894-8008
  • Fax: 530-894-5791
Mailing address:
  • Phone: 530-894-8008
  • Fax: 530-894-5791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: