Healthcare Provider Details

I. General information

NPI: 1871923169
Provider Name (Legal Business Name): DEEPTI PUTCHA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115
US

IV. Provider business mailing address

375 BOYLSTON ST
BROOKLINE MA
02445-6007
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-5500
  • Fax:
Mailing address:
  • Phone: 857-307-0873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number10781
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number10781
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: