Provider Demographics
NPI:1417154410
Name:CANTRELL, PEGGY JOYCE
Entity Type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:JOYCE
Last Name:CANTRELL
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 1:4 BRIARWOOD COURT
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7677
Mailing Address - Country:US
Mailing Address - Phone:423-360-1697
Mailing Address - Fax:423-439-4472
Practice Address - Street 1:807 UNIVERSITY PKWY
Practice Address - Street 2:ETSU CAMPUS
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614-6500
Practice Address - Country:US
Practice Address - Phone:423-439-7777
Practice Address - Fax:423-439-5695
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP-000000901103TA0700X, 103TC0700X
TNP00000901103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging