MEDICARE: DANELL PUGH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	LSW.0009920785	CO
2	104100000X	Social Worker	LSW-2251	HI

General Provider Information

NPI Number	:	1922472125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANELL PUGH

Provider Business Mailing Address
First Line	:	4519 FENCER RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80911-3619
Country	:	US
Telephone Number	:	719-322-6439
Fax Number	:

Provider Business Practice Location Address
First Line	:	BLDG 1657
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80913
Country	:	US
Telephone Number	:	719-322-6439
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/25/2015
Last Update Date	:	11/25/2015

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