1104311745 NPI number — MRS. PEGGY LONGMAN KEPPLE MSW,LCSW, CADC, GC-C

Table of content: MRS. PEGGY LONGMAN KEPPLE MSW,LCSW, CADC, GC-C (NPI 1104311745)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104311745 NPI number — MRS. PEGGY LONGMAN KEPPLE MSW,LCSW, CADC, GC-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEPPLE
Provider First Name:
PEGGY
Provider Middle Name:
LONGMAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW,LCSW, CADC, GC-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LONGMAN
Provider Other First Name:
MARGARET
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104311745
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
RIVERMEND HEALTH / POSITIVE SOBRIETY INSTITUTE
Provider Second Line Business Mailing Address:
680 N. LAKESHORE DR. SUITE 800
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-642-7230
Provider Business Mailing Address Fax Number:
312-642-7055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
POSITIVE SOBRIETY INSTITUTE
Provider Second Line Business Practice Location Address:
680 N. LAKE SHORE DR. SUITE 800
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-642-7230
Provider Business Practice Location Address Fax Number:
312-642-7055
Provider Enumeration Date:
06/26/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  149.022225 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , with the licence number: 34557 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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