Healthcare Provider Details

I. General information

NPI: 1720552078
Provider Name (Legal Business Name): LEON PUTTLER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 N JACKSON ST
JACKSON MI
49201-1266
US

IV. Provider business mailing address

505 N JACKSON ST
JACKSON MI
49201-1266
US

V. Phone/Fax

Practice location:
  • Phone: 517-748-5301
  • Fax:
Mailing address:
  • Phone: 517-748-5301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301010652
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: