Basic Information
| Provider Information | |||||||||
| NPI: | 1932685484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUGH | ||||||||
| FirstName: | TABITHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | ST | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EASTERLING | ||||||||
| OtherFirstName: | TABITHA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 711 AVIGNON DR | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391575120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016056777 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3261 HIGHWAY 49 | ||||||||
| Address2: | |||||||||
| City: | COLLINS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394283876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019216043 | ||||||||
| FaxNumber: | 6019216044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2018 | ||||||||
| LastUpdateDate: | 07/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | S4204 | MS | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.