Provider Demographics
NPI:1093751877
Name:HAWTHORNE, PEGGY ANN
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:ANN
Last Name:HAWTHORNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 HUGHES ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75672-7621
Mailing Address - Country:US
Mailing Address - Phone:903-935-4157
Mailing Address - Fax:
Practice Address - Street 1:616 W RUSSELL PL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3658
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX040751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G2494OtherBLUE CROSS BLUE SHIELD
TX8G2494OtherBLUE CROSS BLUE SHIELD