Provider Demographics
NPI:1073017372
Name:PECK, KAREN ANN (CTRS, CLC, CST, QST)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:ANN
Last Name:PECK
Suffix:
Gender:F
Credentials:CTRS, CLC, CST, QST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:469 BUCKLAND RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3737
Mailing Address - Country:US
Mailing Address - Phone:860-432-9923
Mailing Address - Fax:
Practice Address - Street 1:469 BUCKLAND RD STE 102
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3737
Practice Address - Country:US
Practice Address - Phone:860-432-9923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12771225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist