Healthcare Provider Details

I. General information

NPI: 1659427995
Provider Name (Legal Business Name): SHERIDAN L PECK OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S 200 W
RICHMOND UT
84333-1267
US

IV. Provider business mailing address

1068 S 470 E
PROVIDENCE UT
84332-9501
US

V. Phone/Fax

Practice location:
  • Phone: 435-258-5601
  • Fax:
Mailing address:
  • Phone: 435-752-3920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number282835-4201
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: