Provider Demographics
NPI:1992922603
Name:PICKFORD, PEGGY LYNN (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:LYNN
Last Name:PICKFORD
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:PICKFORD
Other - Last Name:JOSEPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1779 TAIT TER
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23509-1043
Mailing Address - Country:US
Mailing Address - Phone:757-410-2816
Mailing Address - Fax:
Practice Address - Street 1:1779 TAIT TER
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23509-1043
Practice Address - Country:US
Practice Address - Phone:757-410-2816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004739235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004979907Medicaid
VA496647Medicare ID - Type Unspecified