Healthcare Provider Details

I. General information

NPI: 1144975525
Provider Name (Legal Business Name): GENORI PUTNAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 E 55TH ST
CLEVELAND OH
44103-3602
US

IV. Provider business mailing address

1804 E 55TH ST
CLEVELAND OH
44103-3602
US

V. Phone/Fax

Practice location:
  • Phone: 216-762-4737
  • Fax:
Mailing address:
  • Phone: 216-762-1237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberST869333
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: