=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225386295
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELIZABETH MARABELLA PECK, PT, DPT, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2012
-----------------------------------------------------
Last Update Date | 08/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 MAIN ST SUITE 2
-----------------------------------------------------
City | NORTH TONAWANDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14120-5308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-692-6388
-----------------------------------------------------
Fax | 716-692-1227
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 MAIN ST SUITE 2
-----------------------------------------------------
City | NORTH TONAWANDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14120-5308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-692-6388
-----------------------------------------------------
Fax | 716-692-1227
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELIZABETH ANN PECK
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 716-692-6388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 17364-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------