Healthcare Provider Details

I. General information

NPI: 1669112546
Provider Name (Legal Business Name): ALISSA G PUTMAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 05/01/2022
Certification Date: 05/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10045 BALTIMORE NATIONAL PIKE # A71158
ELLICOTT CITY MD
21042-3673
US

IV. Provider business mailing address

10045 BALTIMORE NATIONAL PIKE # A71158
ELLICOTT CITY MD
21042-3673
US

V. Phone/Fax

Practice location:
  • Phone: 410-258-8957
  • Fax:
Mailing address:
  • Phone: 410-258-8957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number04134
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: