Provider Demographics
NPI:1225208838
Name:PECK, THELMA
Entity Type:Individual
Prefix:
First Name:THELMA
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 1:400 NEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-4511
Mailing Address - Country:US
Mailing Address - Phone:304-256-4712
Mailing Address - Fax:
Practice Address - Street 1:400 NEVILLE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4511
Practice Address - Country:US
Practice Address - Phone:304-256-4712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0038235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0155122000Medicaid