Provider Demographics
NPI:1427539337
Name:PUGH, MIRIAM (LICSW)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:PUGH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 BATEMAN ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-4924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 BATEMAN ST
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-4924
Practice Address - Country:US
Practice Address - Phone:617-851-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA117278-SW-LICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical