Provider Demographics
NPI:1073969655
Name:PECK, MOLLY
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
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 1:2111 HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:IRONDEQUOIT
Mailing Address - State:NY
Mailing Address - Zip Code:14617-4346
Mailing Address - Country:US
Mailing Address - Phone:585-467-4567
Mailing Address - Fax:
Practice Address - Street 1:2111 HUDSON AVE
Practice Address - Street 2:
Practice Address - City:IRONDEQUOIT
Practice Address - State:NY
Practice Address - Zip Code:14617-4346
Practice Address - Country:US
Practice Address - Phone:585-467-4567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY804535131174400000X
NY804534131174400000X
NY1025518161174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist