Provider Demographics
NPI:1093544199
Name:PECK, LISA (CPRM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PECK
Suffix:
Gender:F
Credentials:CPRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 S GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3434
Mailing Address - Country:US
Mailing Address - Phone:231-346-5247
Mailing Address - Fax:
Practice Address - Street 1:1010 S GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3434
Practice Address - Country:US
Practice Address - Phone:231-346-5247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist