Provider Demographics
NPI:1003070335
Name:PECK, CATHY EILEEN
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:EILEEN
Last Name:PECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 COQUINA AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-4528
Mailing Address - Country:US
Mailing Address - Phone:904-501-4458
Mailing Address - Fax:
Practice Address - Street 1:45 COQUINA AVE
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-4528
Practice Address - Country:US
Practice Address - Phone:904-501-4458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA38265172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist