Healthcare Provider Details

I. General information

NPI: 1114404720
Provider Name (Legal Business Name): DEIRDRE HURLEY PUTNAM LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CUMMINGS CTR STE 6500
BEVERLY MA
01915-6234
US

IV. Provider business mailing address

17 BUSH HILL RD
IPSWICH MA
01938-1620
US

V. Phone/Fax

Practice location:
  • Phone: 978-236-1763
  • Fax:
Mailing address:
  • Phone: 978-302-4078
  • Fax: 978-236-1702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number114003
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: