Basic Information
| Provider Information | |||||||||
| NPI: | 1871870774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | PEGGY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETERSON | ||||||||
| OtherFirstName: | PEGGY | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816020040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9709452241 | ||||||||
| FaxNumber: | 9709455523 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 OURAY AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815012536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702416099 | ||||||||
| FaxNumber: | 9702410797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2011 | ||||||||
| LastUpdateDate: | 11/07/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.