Healthcare Provider Details

I. General information

NPI: 1003470121
Provider Name (Legal Business Name): DUSTYN RYAN PUTZIER LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51781 HUNTINGTON RD
LA PINE OR
97739-1118
US

IV. Provider business mailing address

11613 CABIN CREEK ST
CALDWELL ID
83605-6793
US

V. Phone/Fax

Practice location:
  • Phone: 541-907-7040
  • Fax: 541-907-7059
Mailing address:
  • Phone: 208-830-4503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW-35806
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: