Healthcare Provider Details

I. General information

NPI: 1952809170
Provider Name (Legal Business Name): PAMELA LUGO BA, MHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAMELA PLUZYCKI

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 E VINE ST
VIENNA IL
62995-1612
US

IV. Provider business mailing address

406 E VINE ST
VIENNA IL
62995-1612
US

V. Phone/Fax

Practice location:
  • Phone: 618-658-3079
  • Fax: 618-658-2759
Mailing address:
  • Phone: 618-658-3079
  • Fax: 618-658-2759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: