MEDICARE: KELSEA DANIELLE PECK LMSW

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	104100000X	Social Worker
2	1041C0700X	Clinical Social Worker	6801112284	MI

General Provider Information

NPI Number	:	1437704327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEA DANIELLE PECK LMSW

Provider Business Mailing Address
First Line	:	3530 STEFFISBURG DR
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37211-8358
Country	:	US
Telephone Number	:	480-529-6034
Fax Number	:

Provider Business Practice Location Address
First Line	:	1150 BALL AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5901
Country	:	US
Telephone Number	:	616-456-6571
Fax Number	:	616-235-0979

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

Provider Enumeration Date	:	08/07/2019
Last Update Date	:	03/18/2024

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