Healthcare Provider Details

I. General information

NPI: 1114337516
Provider Name (Legal Business Name): PUTNAM PSYCHOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 SAINT JOHNS AVE
PALATKA FL
32177-4650
US

IV. Provider business mailing address

918 SAINT JOHNS AVE
PALATKA FL
32177-4650
US

V. Phone/Fax

Practice location:
  • Phone: 386-385-3887
  • Fax: 386-385-3922
Mailing address:
  • Phone: 386-385-3887
  • Fax: 386-385-3922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 5246
License Number StateFL

VIII. Authorized Official

Name: MRS. CINDY DOREEN SHARPE
Title or Position: OFFICE MANAGER
Credential:
Phone: 386-385-3887