Provider Demographics
NPI:1578733697
Name:PAUL, PEGGY (COTA)
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:
Last Name:PAUL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 27TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3102
Mailing Address - Country:US
Mailing Address - Phone:612-332-4262
Mailing Address - Fax:
Practice Address - Street 1:22 27TH AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3102
Practice Address - Country:US
Practice Address - Phone:612-332-4262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities