Provider Demographics
NPI:1801008883
Name:VAN RAALTE, PEGGY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:
Last Name:VAN RAALTE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BRUNSWICK RD
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3027
Mailing Address - Country:US
Mailing Address - Phone:973-746-7822
Mailing Address - Fax:
Practice Address - Street 1:19 BRUNSWICK RD
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3027
Practice Address - Country:US
Practice Address - Phone:973-746-7822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2327103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical