MEDICARE: KELLAN PECK LSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	44SL07325600	NJ

General Provider Information

NPI Number	:	1821951740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLAN PECK LSW

Provider Business Mailing Address
First Line	:	174 NASSAU ST # 308
Second Line	:
City	:	PRINCETON
State	:	NJ
Zip	:	08542-7005
Country	:	US
Telephone Number	:	609-436-0467
Fax Number	:

Provider Business Practice Location Address
First Line	:	707 ALEXANDER RD
Second Line	:
City	:	PRINCETON
State	:	NJ
Zip	:	08540-6331
Country	:	US
Telephone Number	:	609-987-8100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2025
Last Update Date	:	12/08/2025

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