Provider Demographics
NPI:1053816827
Name:TISDALE-BROWN, PEGGIE
Entity type:Individual
Prefix:
First Name:PEGGIE
Middle Name:
Last Name:TISDALE-BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:PEGGIE
Other - Middle Name:TISDALE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1100 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-1944
Mailing Address - Country:US
Mailing Address - Phone:479-443-4301
Mailing Address - Fax:479-587-5994
Practice Address - Street 1:1864 E PARKSHORE DR APT 11
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6268
Practice Address - Country:US
Practice Address - Phone:479-443-4301
Practice Address - Fax:479-587-5994
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8100-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty