Healthcare Provider Details

I. General information

NPI: 1699891754
Provider Name (Legal Business Name): CHERYLL LA VONNE PUTT MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 11/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1371 CORTE BAGALSO
SAN MARCOS CA
92069-7392
US

IV. Provider business mailing address

16776 BERNARDO CENTER DR SUITE 204
SAN DIEGO CA
92128-2534
US

V. Phone/Fax

Practice location:
  • Phone: 858-603-5759
  • Fax: 858-451-9929
Mailing address:
  • Phone: 858-451-9929
  • Fax: 858-451-9929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFC39494
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: