Provider Demographics
NPI:1144747437
Name:PUGH, WILLIE MAE BERRY
Entity type:Individual
Prefix:
First Name:WILLIE MAE
Middle Name:BERRY
Last Name:PUGH
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 1:2013 TEAL CT
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-7951
Mailing Address - Country:US
Mailing Address - Phone:706-790-4961
Mailing Address - Fax:
Practice Address - Street 1:2013 TEAL COURT
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815
Practice Address - Country:US
Practice Address - Phone:706-790-4961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities