=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235363037
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENDRA LYNN PUGH PSY. D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2009
-----------------------------------------------------
Last Update Date | 06/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 W ELLERSLIE AVE
-----------------------------------------------------
City | COLONIAL HEIGHTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834-1513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-520-1655
-----------------------------------------------------
Fax | 804-520-8595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 579
-----------------------------------------------------
City | COLONIAL HEIGHTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834-0579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-520-1655
-----------------------------------------------------
Fax | 804-520-8595
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 0810001789
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------