Provider Demographics
NPI:1063761104
Name:PUGH, MELISSA LYNN (PT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:PUGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 LENOX AVE
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-4980
Mailing Address - Country:US
Mailing Address - Phone:630-818-5055
Mailing Address - Fax:
Practice Address - Street 1:2340 S EOLA RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60503
Practice Address - Country:US
Practice Address - Phone:630-978-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019430225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400195289Medicare PIN
IL202845269Medicare PIN