Healthcare Provider Details

I. General information

NPI: 1740264639
Provider Name (Legal Business Name): PEGGY PACK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2005
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 N UNIVERSITY AVE
LITTLE ROCK AR
72205-2920
US

IV. Provider business mailing address

802 N UNIVERSITY AVE
LITTLE ROCK AR
72205-2920
US

V. Phone/Fax

Practice location:
  • Phone: 501-420-2434
  • Fax: 888-388-5166
Mailing address:
  • Phone: 501-420-2434
  • Fax: 888-388-5166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0785
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11-11P
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: