Provider Demographics
NPI:1003842741
Name:PUGH, KRISTINA MARIE (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:MARIE
Last Name:PUGH
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MS
Other - First Name:KRISTINA
Other - Middle Name:MARIE
Other - Last Name:KRANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LSW
Mailing Address - Street 1:13802 QUINTESSA ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-5153
Mailing Address - Country:US
Mailing Address - Phone:801-599-7123
Mailing Address - Fax:
Practice Address - Street 1:13802 QUINTESSA ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-5153
Practice Address - Country:US
Practice Address - Phone:801-599-7123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-072581041C0700X
OHI 08000881041C0700X
IDLCSW-343101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942938348OtherCHAMPUS
UTE004662169Medicaid
UT00554956Medicare ID - Type UnspecifiedMEDICARE
UT107001404101OtherINTRMTN. HEALTH CARE
S6930Medicare UPIN
UTS693Medicare ID - Type UnspecifiedMEDICARE ADVANTAGE PLANS
UT262141OtherDESERET MUTUAL
UT942938348FOtherEDUCATORS MUTUAL
UT0046621Medicare ID - Type UnspecifiedRAILROAD MEDICARE
UT00554950Medicare ID - Type UnspecifiedRAILROAD MEDICARE
UTMF01167OtherDEA