Provider Demographics
NPI:1063112290
Name:PECK, VIRGINIA ELLAINE
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:ELLAINE
Last Name:PECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 BONSAI CIR APT 211
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-6774
Mailing Address - Country:US
Mailing Address - Phone:561-371-9966
Mailing Address - Fax:
Practice Address - Street 1:4951 BONSAI CIR APT 211
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-6774
Practice Address - Country:US
Practice Address - Phone:561-371-9966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17350101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional