Provider Demographics
NPI:1124310776
Name:PECK, MELISSA (LAC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PECK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3809 S 2ND ST
Mailing Address - Street 2:D100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7036
Mailing Address - Country:US
Mailing Address - Phone:512-892-3366
Mailing Address - Fax:512-892-3384
Practice Address - Street 1:3809 S 2ND ST
Practice Address - Street 2:D100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7036
Practice Address - Country:US
Practice Address - Phone:512-892-3366
Practice Address - Fax:512-892-3384
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-13
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00940171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist