Provider Demographics
NPI:1699776625
Name:PAYONK, PEGGY RUTH (LCSW)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:RUTH
Last Name:PAYONK
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 1:8400 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6385
Mailing Address - Country:US
Mailing Address - Phone:219-757-1928
Mailing Address - Fax:219-757-1950
Practice Address - Street 1:2490 CENTRAL AVE
Practice Address - Street 2:STE D
Practice Address - City:LAKE STATION
Practice Address - State:IN
Practice Address - Zip Code:46405-2122
Practice Address - Country:US
Practice Address - Phone:219-962-4040
Practice Address - Fax:219-960-4042
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004369A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN409190OMedicare ID - Type Unspecified