Healthcare Provider Details

I. General information

NPI: 1619368685
Provider Name (Legal Business Name): BAYLEY NICOLE PUTMAN MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8325 SW 61ST AVE
PORTLAND OR
97219-3109
US

IV. Provider business mailing address

PO BOX 80524
PORTLAND OR
97280-1524
US

V. Phone/Fax

Practice location:
  • Phone: 503-451-0164
  • Fax:
Mailing address:
  • Phone: 503-451-0164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: