Provider Demographics
NPI:1659576981
Name:RANDALL, PEGGY (MA)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:RANDALL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:MORGAN
Other - Middle Name:
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:229 INDRALAYA RD
Mailing Address - Street 2:
Mailing Address - City:EASTSOUND
Mailing Address - State:WA
Mailing Address - Zip Code:98245-9271
Mailing Address - Country:US
Mailing Address - Phone:360-376-5552
Mailing Address - Fax:
Practice Address - Street 1:1420 S 12TH
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274
Practice Address - Country:US
Practice Address - Phone:360-376-5552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00052693101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health