Provider Demographics
NPI:1114408515
Name:PILGRIM, PEGGY SUE
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:SUE
Last Name:PILGRIM
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:PO BOX 502
Mailing Address - Street 2:
Mailing Address - City:ETOILE
Mailing Address - State:TX
Mailing Address - Zip Code:75944-0502
Mailing Address - Country:US
Mailing Address - Phone:409-224-9769
Mailing Address - Fax:
Practice Address - Street 1:355 FM 83 W
Practice Address - Street 2:
Practice Address - City:HEMPHILL
Practice Address - State:TX
Practice Address - Zip Code:75948-8300
Practice Address - Country:US
Practice Address - Phone:409-787-5311
Practice Address - Fax:409-787-5399
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2103700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant