Healthcare Provider Details

I. General information

NPI: 1346648441
Provider Name (Legal Business Name): ASHLEY PUTNAM ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 2ND AVE
DETROIT MI
48202-3006
US

IV. Provider business mailing address

116 ELMWOOD ST
DEARBORN MI
48124-1424
US

V. Phone/Fax

Practice location:
  • Phone: 313-970-8417
  • Fax:
Mailing address:
  • Phone: 814-450-3340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number004572
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001360
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number75
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: