Provider Demographics
NPI:1003291493
Name:PECUKONIS, EDWARD (MSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:PECUKONIS
Suffix:
Gender:M
Credentials:MSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3244 DANMARK DR
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21738-9415
Mailing Address - Country:US
Mailing Address - Phone:410-493-1530
Mailing Address - Fax:
Practice Address - Street 1:3244 DANMARK DR
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MD
Practice Address - Zip Code:21738-9415
Practice Address - Country:US
Practice Address - Phone:410-493-1530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD046421041C0700X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst