Provider Demographics
NPI:1144510645
Name:PECKHAM, CHARLES M (TLLP)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:PECKHAM
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 JEWETT RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-8729
Mailing Address - Country:US
Mailing Address - Phone:517-676-5405
Mailing Address - Fax:517-676-5460
Practice Address - Street 1:2702 FLUSHING RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-4534
Practice Address - Country:US
Practice Address - Phone:810-424-5998
Practice Address - Fax:810-424-6347
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014260103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist