Basic Information
| Provider Information | |||||||||
| NPI: | 1831385392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEYKAR | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LPC, LMFT, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2693 FOREST HILLS RD SW STE D | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278938611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522347800 | ||||||||
| FaxNumber: | 2522347030 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 VANCE ST E | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278934034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522912344 | ||||||||
| FaxNumber: | 2522911436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2007 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2683 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | 535 | NC | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 6105081 | 05 | NC | MEDICAID |