Healthcare Provider Details

I. General information

NPI: 1023553443
Provider Name (Legal Business Name): PEGGY MCCORMICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6775 POINT PLEASANT RD
MILLWOOD WV
25262-8100
US

IV. Provider business mailing address

6775 POINT PLEASANT RD
MILLWOOD WV
25262-8100
US

V. Phone/Fax

Practice location:
  • Phone: 304-273-0112
  • Fax: 304-273-0115
Mailing address:
  • Phone: 304-273-0112
  • Fax: 304-273-0115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberAP00944379
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1600061
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: