Healthcare Provider Details

I. General information

NPI: 1134572308
Provider Name (Legal Business Name): LISA DAVIS PECK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2016
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6644 GREENDALE LN
INDIANAPOLIS IN
46241-1068
US

IV. Provider business mailing address

6644 GREENDALE LN
INDIANAPOLIS IN
46241-1068
US

V. Phone/Fax

Practice location:
  • Phone: 317-919-8482
  • Fax:
Mailing address:
  • Phone: 317-919-8482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001460A
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39001382A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001131A
License Number StateIN

VIII. Authorized Official

Name: LISA MARCELLA DAVIS PECK
Title or Position: OWNER PRESIDENT
Credential: LMHC, LMFT, LCAC
Phone: 317-919-8482