Provider Demographics
NPI:1255514055
Name:GWINN, PEGGY ANN (CDP)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:ANN
Last Name:GWINN
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 PACIFIC AVE APT 505
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4496
Mailing Address - Country:US
Mailing Address - Phone:425-252-5063
Mailing Address - Fax:
Practice Address - Street 1:13000 21ST DR SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-7103
Practice Address - Country:US
Practice Address - Phone:425-338-7671
Practice Address - Fax:425-338-7672
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00003372101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)