Healthcare Provider Details

I. General information

NPI: 1164779138
Provider Name (Legal Business Name): TINA PECK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 W 400 N STE 1
BRIGHAM CITY UT
84302
US

IV. Provider business mailing address

PO BOX 866
BRIGHAM CITY UT
84302-0866
US

V. Phone/Fax

Practice location:
  • Phone: 435-494-1557
  • Fax:
Mailing address:
  • Phone: 435-494-1557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9177224-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: