Provider Demographics
NPI:1003644618
Name:PUGH, MIMI (LADC)
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:PUGH
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 HAZARD AVE # 23
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3713
Mailing Address - Country:US
Mailing Address - Phone:860-506-5765
Mailing Address - Fax:
Practice Address - Street 1:73 WALNUT ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4954
Practice Address - Country:US
Practice Address - Phone:860-506-5765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1574101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)