Healthcare Provider Details

I. General information

NPI: 1699349720
Provider Name (Legal Business Name): CRISTINA PUTNAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 S MAIN ST
LAYTON UT
84041-7135
US

IV. Provider business mailing address

934 S MAIN ST
LAYTON UT
84041-7135
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-7060
  • Fax: 801-336-1787
Mailing address:
  • Phone: 801-773-7060
  • Fax: 801-336-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW17067
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12296736-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: