Healthcare Provider Details

I. General information

NPI: 1447279278
Provider Name (Legal Business Name): PEGGY J ROBERTS MED, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27B SOUTH WEST SUITE #100 AND #200
ARDMORE OK
73401
US

IV. Provider business mailing address

4901 LONGWOOD CT
IRVING TX
75038-3413
US

V. Phone/Fax

Practice location:
  • Phone: 918-388-6227
  • Fax: 918-388-6456
Mailing address:
  • Phone: 972-768-4298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2673
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: