Provider Demographics
NPI:1902409733
Name:PUTU, MASONOR
Entity type:Individual
Prefix:
First Name:MASONOR
Middle Name:
Last Name:PUTU
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 1:9 JEFFERSON ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-4355
Mailing Address - Country:US
Mailing Address - Phone:413-378-5541
Mailing Address - Fax:
Practice Address - Street 1:9 JEFFERSON ST APT 2F
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-4355
Practice Address - Country:US
Practice Address - Phone:413-378-5541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS49616671106S00000X
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician