Provider Demographics
NPI:1417089327
Name:PECKHOLDT, RONALD JOHN (LCSW)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:JOHN
Last Name:PECKHOLDT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 EMMA LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-2688
Mailing Address - Country:US
Mailing Address - Phone:631-775-6858
Mailing Address - Fax:631-924-4454
Practice Address - Street 1:3 EMMA LN
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2688
Practice Address - Country:US
Practice Address - Phone:631-775-6858
Practice Address - Fax:631-924-4454
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR035338101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health