Healthcare Provider Details

I. General information

NPI: 1649662446
Provider Name (Legal Business Name): MANDY MAE PUTNAM CADC II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12180 SE MARKET ST
PORTLAND OR
97216-3923
US

IV. Provider business mailing address

17839 SE HARRISON ST
PORTLAND OR
97233-5123
US

V. Phone/Fax

Practice location:
  • Phone: 971-279-4993
  • Fax:
Mailing address:
  • Phone: 503-935-2848
  • Fax: 503-269-8407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: