Healthcare Provider Details

I. General information

NPI: 1104804574
Provider Name (Legal Business Name): LATICIA PECK SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 PINE LAKE DR
GRAYSON GA
30017-7926
US

IV. Provider business mailing address

1165 PINE LAKE DR
GRAYSON GA
30017-7926
US

V. Phone/Fax

Practice location:
  • Phone: 678-852-4022
  • Fax: 770-972-5577
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP005865
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: