Healthcare Provider Details

I. General information

NPI: 1417154410
Provider Name (Legal Business Name): DR. PEGGY JOYCE CANTRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 UNIVERSITY PKWY ETSU CAMPUS
JOHNSON CITY TN
37614-6500
US

IV. Provider business mailing address

4 BRIARWOOD COURT
JOHNSON CITY TN
37604-7677
US

V. Phone/Fax

Practice location:
  • Phone: 423-439-7777
  • Fax: 423-439-5695
Mailing address:
  • Phone: 423-360-1697
  • Fax: 423-439-4472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberP-000000901
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP-000000901
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP00000901
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: