Healthcare Provider Details

I. General information

NPI: 1043835408
Provider Name (Legal Business Name): LIFE TREE PSYCHOLOGICAL SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 W. SIERRA MADRE BLVD.
SIERRA MADRE CA
91024
US

IV. Provider business mailing address

150 W. SIERRA MADRE BLVD
SIERRA MADRE CA
91024
US

V. Phone/Fax

Practice location:
  • Phone: 626-808-7534
  • Fax: 626-921-0005
Mailing address:
  • Phone: 626-808-7534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. KATHARINE M PUTMAN
Title or Position: OWNER
Credential: PSY.D.
Phone: 626-808-7534