Provider Demographics
NPI:1285762211
Name:SELLS, PEGGY R (LBSW)
Entity type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:R
Last Name:SELLS
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3074 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-2938
Mailing Address - Country:US
Mailing Address - Phone:515-576-1643
Mailing Address - Fax:
Practice Address - Street 1:3074 10TH AVE N
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-2938
Practice Address - Country:US
Practice Address - Phone:515-576-1643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04800171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1010306Medicaid