Provider Demographics
NPI:1649843970
Name:PUGEDA, MARILOU GELINDON
Entity type:Individual
Prefix:
First Name:MARILOU
Middle Name:GELINDON
Last Name:PUGEDA
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 1:5048 SOUTHAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-6965
Mailing Address - Country:US
Mailing Address - Phone:907-331-7220
Mailing Address - Fax:
Practice Address - Street 1:5048 SOUTHAMPTON DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-6965
Practice Address - Country:US
Practice Address - Phone:907-331-7220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101558320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities