MEDICARE: MICHELLE DIANE PECKHAM

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	101YM0800X	Mental Health Counselor	3581	KS
2	101YM0800X	Mental Health Counselor	03848	KS

General Provider Information

NPI Number	:	1538805247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE DIANE PECKHAM

Provider Business Mailing Address
First Line	:	4319 N BARTON CREEK CIR
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67226-4229
Country	:	US
Telephone Number	:	316-214-9879
Fax Number	:

Provider Business Practice Location Address
First Line	:	8080 E CENTRAL AVE STE 320
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67206-2389
Country	:	US
Telephone Number	:	316-927-3010
Fax Number	:

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

Provider Enumeration Date	:	05/06/2022
Last Update Date	:	10/31/2024

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Directions to “ MICHELLE DIANE PECKHAM ” Practice Location

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