Healthcare Provider Details

I. General information

NPI: 1770803322
Provider Name (Legal Business Name): CLARALICE PUTNAM M.ED., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2010
Last Update Date: 07/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 S BROADWAY AVE AMERICAN BUILDING-SUITE 406
ADA OK
74820-5820
US

IV. Provider business mailing address

1800 E 18TH ST
ADA OK
74820-7115
US

V. Phone/Fax

Practice location:
  • Phone: 580-310-4750
  • Fax: 580-559-2223
Mailing address:
  • Phone: 580-310-4750
  • Fax: 580-559-2223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2311
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: