Provider Demographics
NPI:1730568973
Name:PUTNA, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:PUTNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 NW 19TH AVE
Mailing Address - Street 2:SUITE 301C
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1401
Mailing Address - Country:US
Mailing Address - Phone:503-470-9436
Mailing Address - Fax:
Practice Address - Street 1:811 NW 19TH AVE
Practice Address - Street 2:SUITE 301C
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1401
Practice Address - Country:US
Practice Address - Phone:503-470-9436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR3420101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health