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General NPI Number Information
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NPI Number | 1144747437
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Entity Type | Individual
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Provider Name | WILLIE MAE BERRY PUGH
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Gender | Female
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Dates
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Enumeration Date | 08/28/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2013 TEAL COURT
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City | HEPHZIBAH
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State | GA
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Zip | 30815
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Country | US
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Telephone | 706-790-4961
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Fax |
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Provider Business Mailing Address
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Address Line | 2013 TEAL CT
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City | HEPHZIBAH
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State | GA
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Zip | 30815-7951
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Country | US
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Telephone | 706-790-4961
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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