Healthcare Provider Details

I. General information

NPI: 1811943830
Provider Name (Legal Business Name): EDWARD ARNOLD PECK III PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 BREMO RD SUITE 127
RICHMOND VA
23226-2444
US

IV. Provider business mailing address

2010 BREMO RD SUITE 127
RICHMOND VA
23226-2444
US

V. Phone/Fax

Practice location:
  • Phone: 804-285-2555
  • Fax: 804-282-0314
Mailing address:
  • Phone: 804-285-2555
  • Fax: 804-282-0314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810000910
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810000910
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2228
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: