Provider Demographics
NPI:1578037354
Name:PUGA-MARTINEZ, JOHANNA YVETTE
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:YVETTE
Last Name:PUGA-MARTINEZ
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 1:8124 ALGERITA CT
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79915-4604
Mailing Address - Country:US
Mailing Address - Phone:915-256-1231
Mailing Address - Fax:
Practice Address - Street 1:10450 BRIAN MOONEY AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-2809
Practice Address - Country:US
Practice Address - Phone:915-598-6616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115134235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX235200000XMedicaid