Healthcare Provider Details

I. General information

NPI: 1093396319
Provider Name (Legal Business Name): PUTNAM COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5641 BURKE CENTRE PKWY STE 124
BURKE VA
22015-2259
US

IV. Provider business mailing address

PO BOX 12511
BURKE VA
22009-2511
US

V. Phone/Fax

Practice location:
  • Phone: 571-314-5582
  • Fax:
Mailing address:
  • Phone: 616-826-6067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: CORIELLE PUTNAM
Title or Position: OWNER
Credential: LPC
Phone: 616-826-6067