Provider Demographics
NPI:1427090034
Name:REYNOLDS HALL, PEGGY JOLI (LCSW)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:JOLI
Last Name:REYNOLDS HALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12728 AUGUSTA AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-3753
Mailing Address - Country:US
Mailing Address - Phone:402-330-1537
Mailing Address - Fax:402-330-9331
Practice Address - Street 1:12728 AUGUSTA AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3753
Practice Address - Country:US
Practice Address - Phone:402-330-1537
Practice Address - Fax:402-330-9331
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE849101Y00000X
NE2691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE120644000OtherMAGELLAN
NE470789060000Medicaid
NE470789060000Medicaid