Healthcare Provider Details

I. General information

NPI: 1972012888
Provider Name (Legal Business Name): ELIZABETH RAE PECK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2017
Last Update Date: 09/29/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF ROUTE N12 AND N7
FORT DEFIANCE AZ
86504-0649
US

IV. Provider business mailing address

PO BOX 649
FORT DEFIANCE AZ
86504-0649
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT22325
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: