Healthcare Provider Details

I. General information

NPI: 1396112629
Provider Name (Legal Business Name): DUSTIN DANIEL PECK LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2015
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 N 10TH ST SUITE 110
KALAMAZOO MI
49009-5733
US

IV. Provider business mailing address

1302 117TH AVE
OTSEGO MI
49078-9723
US

V. Phone/Fax

Practice location:
  • Phone: 269-375-4363
  • Fax:
Mailing address:
  • Phone: 269-365-1419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801090454
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: