Healthcare Provider Details

I. General information

NPI: 1013423367
Provider Name (Legal Business Name): TYLER MATTHEW PECKHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2017
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3359 KEMP RD STE 200
BEAVERCREEK OH
45431-2567
US

IV. Provider business mailing address

303 W ROSS ST
TROY OH
45373-3931
US

V. Phone/Fax

Practice location:
  • Phone: 937-490-2090
  • Fax: 937-490-2780
Mailing address:
  • Phone: 937-216-9282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.2505064
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: