Provider Demographics
NPI:1093497471
Name:PECK, BRANDON LEE (PTA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:LEE
Last Name:PECK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9861 VICTORIA LN
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-5140
Mailing Address - Country:US
Mailing Address - Phone:210-627-5084
Mailing Address - Fax:
Practice Address - Street 1:630 W WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3348
Practice Address - Country:US
Practice Address - Phone:210-736-3177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2177205225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant