Provider Demographics
NPI:1962915066
Name:PECK, STEPHANIE A (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:PECK
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 GRANDIN RD SW # 243
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-2349
Mailing Address - Country:US
Mailing Address - Phone:202-744-1185
Mailing Address - Fax:
Practice Address - Street 1:109 KNOTBREAK RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-5404
Practice Address - Country:US
Practice Address - Phone:540-772-8022
Practice Address - Fax:540-772-0294
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119007502225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist