Provider Demographics
NPI:1851610968
Name:PUGH, KOZETTA LINETTE (OTA)
Entity Type:Individual
Prefix:
First Name:KOZETTA
Middle Name:LINETTE
Last Name:PUGH
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:KOZETTA
Other - Middle Name:LINETTE
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTA
Mailing Address - Street 1:11860 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1036
Mailing Address - Country:US
Mailing Address - Phone:708-361-4555
Mailing Address - Fax:
Practice Address - Street 1:11860 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1036
Practice Address - Country:US
Practice Address - Phone:708-361-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057-002956224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant