Provider Demographics
NPI:1255866828
Name:PEGRAM, MAXINE
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:PEGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAXINE
Other - Middle Name:N
Other - Last Name:PEGRAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:1777 AXTELL DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4404
Mailing Address - Country:US
Mailing Address - Phone:248-867-0490
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4404
Practice Address - Country:US
Practice Address - Phone:248-385-1193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016428103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical