Provider Demographics
NPI:1104367788
Name:PUGH, CLARISSA DIONE
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:DIONE
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 1:4352 CARLYLE LOOP
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71302-2864
Mailing Address - Country:US
Mailing Address - Phone:318-308-3058
Mailing Address - Fax:
Practice Address - Street 1:3600 JACKSON ST STE 119
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3096
Practice Address - Country:US
Practice Address - Phone:318-308-3058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA9857OtherOTHERS