MEDICARE: LATICIA PECK SLP

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	235Z00000X	Speech-Language Pathologist	SLP005865	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104804574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATICIA PECK SLP

Provider Business Mailing Address
First Line	:	1165 PINE LAKE DR
Second Line	:
City	:	GRAYSON
State	:	GA
Zip	:	30017-7926
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1165 PINE LAKE DR
Second Line	:
City	:	GRAYSON
State	:	GA
Zip	:	30017-7926
Country	:	US
Telephone Number	:	678-852-4022
Fax Number	:	770-972-5577

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

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	04/28/2009

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Directions to “ LATICIA PECK SLP” Practice Location

Language	Start Address	Practice Location

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