Provider Demographics
NPI:1467073585
Name:UNDERWOOD, PEGGY SUE
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:SUE
Last Name:UNDERWOOD
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 1:6202 CONSTITUTION DR STE D
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1583
Mailing Address - Country:US
Mailing Address - Phone:260-432-0066
Mailing Address - Fax:
Practice Address - Street 1:105 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-1204
Practice Address - Country:US
Practice Address - Phone:574-268-0448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health