MEDICARE: MR. JUDY SUSAN PECKHAM LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	002790	MO

General Provider Information

NPI Number	:	1033323175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUDY SUSAN PECKHAM LPC

Provider Business Mailing Address
First Line	:	6928 SHADY LAWN DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-5316
Country	:	US
Telephone Number	:	314-846-0553
Fax Number	:

Provider Business Practice Location Address
First Line	:	5127 LEMAY FERRY RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-1533
Country	:	US
Telephone Number	:	314-487-5127
Fax Number	:	314-487-5127

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	07/08/2007

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