Provider Demographics
NPI:1093597601
Name:PUGH, MICKEAL JR (PHD)
Entity Type:Individual
Prefix:
First Name:MICKEAL
Middle Name:
Last Name:PUGH
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 WILSHIRE BLVD APT 619
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-5786
Mailing Address - Country:US
Mailing Address - Phone:717-698-2173
Mailing Address - Fax:
Practice Address - Street 1:11500 W OLYMPIC BLVD STE 640
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1525
Practice Address - Country:US
Practice Address - Phone:424-225-1845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist