Healthcare Provider Details

I. General information

NPI: 1225654809
Provider Name (Legal Business Name): PUTT PEDIATRIC SPEECH AND LANGUAGE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57657 BOULDER CT
GOSHEN IN
46528-7860
US

IV. Provider business mailing address

57657 BOULDER CT
GOSHEN IN
46528-7860
US

V. Phone/Fax

Practice location:
  • Phone: 574-849-0037
  • Fax: 574-807-9564
Mailing address:
  • Phone: 574-849-0037
  • Fax: 574-807-9564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. KAITLIN HELENE PUTT
Title or Position: SPEECH LANGUAGE PATHOLOGIST, CEO
Credential: M.A. CCC-SLP
Phone: 574-387-3567