Provider Demographics
NPI:1578206363
Name:PEGASUS THERAPY LLC
Entity Type:Organization
Organization Name:PEGASUS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:LLPC
Authorized Official - Phone:810-650-2732
Mailing Address - Street 1:635 SAINT ANDREWS
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-4295
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:635 SAINT ANDREWS
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MI
Practice Address - Zip Code:48079-4295
Practice Address - Country:US
Practice Address - Phone:810-650-2732
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty