Provider Demographics
NPI:1396112629
Name:PECK, DUSTIN DANIEL (LMSW)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:DANIEL
Last Name:PECK
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 117TH AVE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MI
Mailing Address - Zip Code:49078-9723
Mailing Address - Country:US
Mailing Address - Phone:269-365-1419
Mailing Address - Fax:
Practice Address - Street 1:1090 N 10TH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-5733
Practice Address - Country:US
Practice Address - Phone:269-375-4363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010904541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical