Provider Demographics
NPI:1124035084
Name:PUTZKA, GREGOR JAMES (MFT)
Entity type:Individual
Prefix:
First Name:GREGOR
Middle Name:JAMES
Last Name:PUTZKA
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 SHANGRILA LN
Mailing Address - Street 2:
Mailing Address - City:ROGUE RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97537-9600
Mailing Address - Country:US
Mailing Address - Phone:831-915-8648
Mailing Address - Fax:831-625-4764
Practice Address - Street 1:130 SHANGRILA LN
Practice Address - Street 2:
Practice Address - City:ROGUE RIVER
Practice Address - State:OR
Practice Address - Zip Code:97537-9600
Practice Address - Country:US
Practice Address - Phone:831-915-8648
Practice Address - Fax:831-625-4764
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18538106H00000X
CALMFT 18538106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11246563OtherBLUE SHIELD
CAZZZ18300ZMedicare ID - Type Unspecified