Provider Demographics
NPI:1003544255
Name:PUGA, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PUGA
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 1:4718 E 59TH PL
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90270-3302
Mailing Address - Country:US
Mailing Address - Phone:323-348-8302
Mailing Address - Fax:
Practice Address - Street 1:5717 E BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-2823
Practice Address - Country:US
Practice Address - Phone:323-430-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA900471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical