Provider Demographics
NPI:1235883075
Name:GROGAN, PEGGY MARY
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:MARY
Last Name:GROGAN
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 1:1721 TIMBER EDGE DR
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-7985
Mailing Address - Country:US
Mailing Address - Phone:386-589-6313
Mailing Address - Fax:386-626-2675
Practice Address - Street 1:1721 TIMBER EDGE DR
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-7985
Practice Address - Country:US
Practice Address - Phone:386-589-6313
Practice Address - Fax:386-626-2675
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12-12-010320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities