Provider Demographics
NPI:1477262319
Name:TYSON, PEGGY (LPC)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 RED BRIDGE COURT
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7432
Mailing Address - Country:US
Mailing Address - Phone:314-780-2146
Mailing Address - Fax:
Practice Address - Street 1:530 RED BRIDGE COURT
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-7923
Practice Address - Country:US
Practice Address - Phone:314-780-2146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002024449101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health