Provider Demographics
NPI:1760004436
Name:PEDDYCORD, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:PEDDYCORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7880 STOKES LINE LN
Mailing Address - Street 2:
Mailing Address - City:WALNUT COVE
Mailing Address - State:NC
Mailing Address - Zip Code:27052-9684
Mailing Address - Country:US
Mailing Address - Phone:336-692-5424
Mailing Address - Fax:
Practice Address - Street 1:5175 OLD CLEMMONS SCHOOL ROAD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27102
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:888-261-6694
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician