Healthcare Provider Details

I. General information

NPI: 1902532872
Provider Name (Legal Business Name): PEGGY CLINTON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22663 KINNEGAD DR
GREAT MILLS MD
20634-3481
US

IV. Provider business mailing address

22663 KINNEGAD DR
GREAT MILLS MD
20634-3481
US

V. Phone/Fax

Practice location:
  • Phone: 240-561-1960
  • Fax:
Mailing address:
  • Phone: 240-561-1960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number17186
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: