Provider Demographics
NPI:1417960279
Name:PUGH, PHYLLIS E (LPC, CSAC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:E
Last Name:PUGH
Suffix:
Gender:F
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MEDICAL DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1765
Mailing Address - Country:US
Mailing Address - Phone:757-788-0092
Mailing Address - Fax:757-788-0969
Practice Address - Street 1:200 MEDICAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1763
Practice Address - Country:US
Practice Address - Phone:757-788-0200
Practice Address - Fax:757-788-0950
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003667101YP2500X
VA0710101505101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-45573Medicaid
VA49-45573Medicaid