Healthcare Provider Details

I. General information

NPI: 1518167394
Provider Name (Legal Business Name): DANIEL JOHN PELAK LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 SAKELARES BLVD
GRANTS NM
87020-3819
US

IV. Provider business mailing address

1040 SAKELARES BLVD
GRANTS NM
87020-3819
US

V. Phone/Fax

Practice location:
  • Phone: 318-245-5791
  • Fax:
Mailing address:
  • Phone: 505-287-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP15112129
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5511
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberCMF0187581
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0183181
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: