=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235883075
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PEGGY MARY GROGAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2022
-----------------------------------------------------
Last Update Date | 02/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1721 TIMBER EDGE DR
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32724-7985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-589-6313
-----------------------------------------------------
Fax | 386-626-2675
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1721 TIMBER EDGE DR
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32724-7985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-589-6313
-----------------------------------------------------
Fax | 386-626-2675
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 12-12-010
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------