Provider Demographics
NPI:1912045584
Name:PEAVY, PAUL THOMAS (MS, LMHC)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:THOMAS
Last Name:PEAVY
Suffix:
Gender:M
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1678 COPPERFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-3791
Mailing Address - Country:US
Mailing Address - Phone:850-264-5033
Mailing Address - Fax:850-907-0237
Practice Address - Street 1:1678 COPPERFIELD CIR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-3791
Practice Address - Country:US
Practice Address - Phone:850-264-5033
Practice Address - Fax:850-907-0237
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4440101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76084033Medicaid