Basic Information
Provider Information
NPI: 1003141359
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PUGH
FirstName: AMY
MiddleName: E
NamePrefix: MRS.
NameSuffix:  
Credential: PSYD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: FORD
OtherFirstName: AMY
OtherMiddleName: E
OtherNamePrefix: MS.
OtherNameSuffix:  
OtherCredential: PSYD
OtherLastNameType: 1
Mailing Information
Address1: 100 MICHIGAN ST NE # MC845
Address2:  
City: GRAND RAPIDS
State: MI
PostalCode: 495032560
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 35 MICHIGAN ST NE STE 5201
Address2:  
City: GRAND RAPIDS
State: MI
PostalCode: 495032514
CountryCode: US
TelephoneNumber: 6162672830
FaxNumber: 6162679024
Other Information
ProviderEnumerationDate: 10/05/2009
LastUpdateDate: 08/03/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TC2200X  Y Behavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent

No ID Information.


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