Provider Demographics
NPI:1265680201
Name:PUGH, JOAN (PSYD)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:PUGH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7650 SW BEVELAND RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:503-601-3615
Mailing Address - Fax:503-646-1683
Practice Address - Street 1:1508 DIVISION ST STE 205
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1585
Practice Address - Country:US
Practice Address - Phone:503-657-1071
Practice Address - Fax:503-657-3321
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2345103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500713781Medicaid