Provider Demographics
NPI:1649667288
Name:PUGA, SUSANNA
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:PUGA
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 1:252 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4012
Mailing Address - Country:US
Mailing Address - Phone:951-318-1351
Mailing Address - Fax:
Practice Address - Street 1:1096 CALIMESA BLVD STE 110
Practice Address - Street 2:
Practice Address - City:CALIMESA
Practice Address - State:CA
Practice Address - Zip Code:92320-1563
Practice Address - Country:US
Practice Address - Phone:951-800-5213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMFT 83842106H00000X
CA138908106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist