Provider Demographics
NPI:1457545964
Name:PUGH-RIVETTE, JULIE RENE' (LISW)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:RENE'
Last Name:PUGH-RIVETTE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W BROADWAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5638
Mailing Address - Country:US
Mailing Address - Phone:505-566-0338
Mailing Address - Fax:
Practice Address - Street 1:1001 W BROADWAY
Practice Address - Street 2:SUITE D
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5638
Practice Address - Country:US
Practice Address - Phone:505-566-0338
Practice Address - Fax:505-327-7247
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-060551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM98320751Medicaid