Healthcare Provider Details

I. General information

NPI: 1316189566
Provider Name (Legal Business Name): KELLY PECK MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 04/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 S SEPULVEDA BLVD
LOS ANGELES CA
90025-4313
US

IV. Provider business mailing address

27023 TIMBERLINE TER
VALENCIA CA
91381-0623
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-6222
  • Fax: 310-478-6696
Mailing address:
  • Phone: 213-309-5767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT22097
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: