Provider Demographics
NPI:1720171382
Name:MAKI, PEGGY SUSAN
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:SUSAN
Last Name:MAKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 CARLSON PKWY
Mailing Address - Street 2:SUITE 1050
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5203
Mailing Address - Country:US
Mailing Address - Phone:970-286-8765
Mailing Address - Fax:
Practice Address - Street 1:601 CARLSON PKWY
Practice Address - Street 2:SUITE 1050
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5203
Practice Address - Country:US
Practice Address - Phone:970-286-8765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 5729103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical