Healthcare Provider Details

I. General information

NPI: 1205293222
Provider Name (Legal Business Name): RACHEL ANN PUTNAM LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

884 BROADWAY SUITE 15
SOUTH PORTLAND ME
04106-4371
US

IV. Provider business mailing address

884 BROADWAY SUITE 15
SOUTH PORTLAND ME
04106-4371
US

V. Phone/Fax

Practice location:
  • Phone: 207-409-5097
  • Fax: 603-929-5958
Mailing address:
  • Phone: 207-409-5097
  • Fax: 603-929-5958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT4967
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: