Healthcare Provider Details

I. General information

NPI: 1699813238
Provider Name (Legal Business Name): PEGGY CHRISTINA GRYDER MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11914 ACORN CREEK TRL
AUSTIN TX
78750-1455
US

IV. Provider business mailing address

11914 ACORN CREEK TRL
AUSTIN TX
78750-1455
US

V. Phone/Fax

Practice location:
  • Phone: 512-585-2692
  • Fax: 512-249-7675
Mailing address:
  • Phone: 512-585-2692
  • Fax: 512-249-7675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number20295
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: