Basic Information
Provider Information | |||||||||
NPI: | 1063820108 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PUTNAM | ||||||||
FirstName: | CHRISTIE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ADER | ||||||||
OtherFirstName: | CHRISTIE | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 142 E 600 NORTH RD | ||||||||
Address2: |   | ||||||||
City: | BUCKLEY | ||||||||
State: | IL | ||||||||
PostalCode: | 609189784 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8154745228 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1001 E PELLS ST | ||||||||
Address2: |   | ||||||||
City: | PAXTON | ||||||||
State: | IL | ||||||||
PostalCode: | 609571300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2173794361 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2014 | ||||||||
LastUpdateDate: | 05/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070.019367 | IL | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.