Provider Demographics
NPI:1508154352
Name:LOO, PEGGY (PHD)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:LOO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:PEGGY
Other - Middle Name:
Other - Last Name:LOO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:461 W 150TH ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-2729
Mailing Address - Country:US
Mailing Address - Phone:630-363-3517
Mailing Address - Fax:
Practice Address - Street 1:580 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-3223
Practice Address - Country:US
Practice Address - Phone:212-271-0216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178006354101YP2500X
NY023109103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional