Provider Demographics
NPI:1083144737
Name:PECK, TAMATHA (MASTER OF ARTS)
Entity Type:Individual
Prefix:
First Name:TAMATHA
Middle Name:
Last Name:PECK
Suffix:
Gender:F
Credentials:MASTER OF ARTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 TERRACE CIR APT 8C
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4182
Mailing Address - Country:US
Mailing Address - Phone:516-302-5379
Mailing Address - Fax:
Practice Address - Street 1:20 TERRACE CIR APT 8C
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4182
Practice Address - Country:US
Practice Address - Phone:516-302-5379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005758225200000X
NY023515235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant