Healthcare Provider Details

I. General information

NPI: 1033479068
Provider Name (Legal Business Name): ELIZABETH ANN PUTELIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2012
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 SW CUTOFF STE 203
WORCESTER MA
01604-2730
US

IV. Provider business mailing address

105 WALLACE AVE
AUBURN MA
01501-1103
US

V. Phone/Fax

Practice location:
  • Phone: 508-341-2829
  • Fax:
Mailing address:
  • Phone: 508-981-1930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2047
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: