Provider Demographics
NPI:1871338921
Name:PUNG, AUBRYANA LACY WEDGE (LLMSW)
Entity type:Individual
Prefix:
First Name:AUBRYANA
Middle Name:LACY WEDGE
Last Name:PUNG
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:AUBRYANA
Other - Middle Name:LACY
Other - Last Name:WEDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLMSW
Mailing Address - Street 1:830 W LAKE LANSING RD STE 200
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-6372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 W LAKE LANSING RD STE 200
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6372
Practice Address - Country:US
Practice Address - Phone:517-624-1416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-29
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511164691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical