Provider Demographics
NPI:1104688001
Name:PURUGGANAN, ANNALIZA I
Entity type:Individual
Prefix:
First Name:ANNALIZA
Middle Name:
Last Name:PURUGGANAN
Suffix:I
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 1:118 CLEVELAND STREET
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148
Mailing Address - Country:US
Mailing Address - Phone:781-521-8287
Mailing Address - Fax:
Practice Address - Street 1:118 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-6226
Practice Address - Country:US
Practice Address - Phone:781-521-8297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X, 101Y00000X
LA5894103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily