Provider Information for 1164779138
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TINA PECK LCSW
Sex: Female
NPI: 1164779138
Last Updated: 2019-08-15
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| NPI | 1164779138 | ||||||||
| Enumeration Date | 2012-08-09 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | PO BOX 866 BRIGHAM CITY, UT 84302-0866 United States Phone: 435-494-1557 | Fax: | ||||||||
| Primary Practice Address | 34 W 400 N STE 1 BRIGHAM CITY, UT 84302 United States Phone: 435-494-1557 | Fax: | ||||||||
| Secondary Practice Address(es) | 34 W 400 N STE 1 | ||||||||
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