Provider Demographics
NPI:1811775133
Name:RUSSELL, PEGGY (PHD)
Entity type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 OAK HAMMOCK LN
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-4521
Mailing Address - Country:US
Mailing Address - Phone:850-212-4655
Mailing Address - Fax:
Practice Address - Street 1:4509 NW 23RD AVE STE D
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6570
Practice Address - Country:US
Practice Address - Phone:772-801-0802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9008103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist