Provider Demographics
NPI:1740264639
Name:PACK, PEGGY (PHD)
Entity type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:
Last Name:PACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-2920
Mailing Address - Country:US
Mailing Address - Phone:501-420-2434
Mailing Address - Fax:888-388-5166
Practice Address - Street 1:802 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-2920
Practice Address - Country:US
Practice Address - Phone:501-420-2434
Practice Address - Fax:888-388-5166
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-03
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0785103TC0700X
AR11-11P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP01014233OtherRR MEDICARE
KY1200633OtherCHA
AR13386583OtherHEALTHLINK
AR190865719Medicaid
AR11386583OtherHEALTHLINK
AR5V939OtherAR BCBS
KYHUKY0818OtherCORPHEALTH
AR12020012900OtherQUALCHOICE
KY000000033491OtherANTHEM
AR5V939OtherAR BCBS
AR11386583OtherHEALTHLINK
AR335682Medicare UPIN