Provider Demographics
NPI:1699054031
Name:PECKMAN, KRISTIN MARIE (MS, EIS)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:PECKMAN
Suffix:
Gender:F
Credentials:MS, EIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 ANITA DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75041-2703
Mailing Address - Country:US
Mailing Address - Phone:972-490-9055
Mailing Address - Fax:972-265-0392
Practice Address - Street 1:320 CUSTER RD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-5623
Practice Address - Country:US
Practice Address - Phone:972-490-9055
Practice Address - Fax:972-265-0392
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171M00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator