Provider Demographics
NPI:1215500541
Name:PECK, M. ELAINE (LCSW)
Entity type:Individual
Prefix:
First Name:M. ELAINE
Middle Name:
Last Name:PECK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9159 WESTDRUM CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46231-3108
Mailing Address - Country:US
Mailing Address - Phone:317-490-3584
Mailing Address - Fax:
Practice Address - Street 1:9159 WESTDRUM CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46231-3108
Practice Address - Country:US
Practice Address - Phone:317-490-3584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002075A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker