=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649328964
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA ANN PECK LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4236 59TH ST W
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34209-6664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-792-8899
-----------------------------------------------------
Fax | 941-795-7536
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5415 13TH AVENUE DR W
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34209-4239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-792-8899
-----------------------------------------------------
Fax | 941-795-7536
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | MH2975
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------