Provider Demographics
NPI:1770143109
Name:PEGGY LISS MSW, L.L.C.
Entity type:Organization
Organization Name:PEGGY LISS MSW, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:LISS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:269-598-3886
Mailing Address - Street 1:2311 GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1978
Mailing Address - Country:US
Mailing Address - Phone:269-598-3886
Mailing Address - Fax:
Practice Address - Street 1:2311 GLENWOOD DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1978
Practice Address - Country:US
Practice Address - Phone:269-598-3886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1285690685Medicaid