Provider Demographics
NPI:1285415737
Name:PUGH, LISA (LMBT 7027)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PUGH
Suffix:
Gender:F
Credentials:LMBT 7027
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 NEW BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-5430
Mailing Address - Country:US
Mailing Address - Phone:910-546-3422
Mailing Address - Fax:
Practice Address - Street 1:513 NEW BRIDGE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-5430
Practice Address - Country:US
Practice Address - Phone:910-546-3422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7027225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist