Healthcare Provider Details

I. General information

NPI: 1538941703
Provider Name (Legal Business Name): JOHN CONNOR PUTNEY CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 BERGER RD
PADUCAH KY
42003-4522
US

IV. Provider business mailing address

220 BERGER RD
PADUCAH KY
42003-4522
US

V. Phone/Fax

Practice location:
  • Phone: 270-441-0030
  • Fax:
Mailing address:
  • Phone: 270-816-4285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number258220
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: