Healthcare Provider Details

I. General information

NPI: 1598075590
Provider Name (Legal Business Name): PEGGY LOUISE BURCHARD-BALLARD MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2010
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S 24TH ST SIMON COTTAGE
QUINCY IL
62301-4446
US

IV. Provider business mailing address

205 S 24TH ST SIMON COTTAGE
QUINCY IL
62301-4446
US

V. Phone/Fax

Practice location:
  • Phone: 217-222-0034
  • Fax: 217-222-3865
Mailing address:
  • Phone: 217-222-0034
  • Fax: 217-222-3865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.007358
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: