Healthcare Provider Details

I. General information

NPI: 1982850509
Provider Name (Legal Business Name): MR. JOSHUA EBEN PUTNAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 DORCHESTER AVE UNIT 604
BOSTON MA
02124-3781
US

IV. Provider business mailing address

1910 DORCHESTER AVE UNIT 604
BOSTON MA
02124-3781
US

V. Phone/Fax

Practice location:
  • Phone: 603-591-9084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8272
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: