Provider Demographics
NPI:1689210916
Name:PUGH, SHANNON MERCER
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MERCER
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 1:5755 N POINT PKWY STE 240
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-1173
Mailing Address - Country:US
Mailing Address - Phone:571-201-3584
Mailing Address - Fax:
Practice Address - Street 1:5755 N POINT PKWY STE 240
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-1173
Practice Address - Country:US
Practice Address - Phone:571-201-3584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007184101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health