Provider Demographics
NPI:1114003886
Name:PECK, MARIE E (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:E
Last Name:PECK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1315
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-3315
Mailing Address - Country:US
Mailing Address - Phone:541-567-9414
Mailing Address - Fax:541-567-0395
Practice Address - Street 1:525 E HURLBURT AVE
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838
Practice Address - Country:US
Practice Address - Phone:541-567-9414
Practice Address - Fax:541-567-0395
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL07121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
90432OtherNAADAC
000TLBMJMedicare ID - Type Unspecified