Provider Demographics
NPI:1073797833
Name:DERIVAN, PEGGY S (MS, LMHC)
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:S
Last Name:DERIVAN
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:S
Other - Last Name:GOLD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, LMHC
Mailing Address - Street 1:590 TITUS AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617
Mailing Address - Country:US
Mailing Address - Phone:585-766-3082
Mailing Address - Fax:585-266-9336
Practice Address - Street 1:590 TITUS AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14617
Practice Address - Country:US
Practice Address - Phone:585-766-3082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000654-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health