Healthcare Provider Details

I. General information

NPI: 1417636473
Provider Name (Legal Business Name): EMILY LAUREN PUTNAM PHD, LCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 AVEMORE SQUARE PL
CHARLOTTESVILLE VA
22911-7228
US

IV. Provider business mailing address

3040 AVEMORE SQUARE PL
CHARLOTTESVILLE VA
22911-7228
US

V. Phone/Fax

Practice location:
  • Phone: 434-220-0089
  • Fax:
Mailing address:
  • Phone: 919-523-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810008137
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: