Healthcare Provider Details

I. General information

NPI: 1790242212
Provider Name (Legal Business Name): ELIZABETH RUSSO PUTNAM MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 MOUNTAIN AVE
SUMMIT NJ
07901
US

IV. Provider business mailing address

88 MOUNTAIN AVE
SUMMIT NJ
07901
US

V. Phone/Fax

Practice location:
  • Phone: 201-572-6237
  • Fax:
Mailing address:
  • Phone: 201-572-6237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number46TR00378100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: