Provider Demographics
NPI:1225386295
Name:ELIZABETH MARABELLA PECK, PT, DPT, PLLC
Entity Type:Organization
Organization Name:ELIZABETH MARABELLA PECK, PT, DPT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:716-692-6388
Mailing Address - Street 1:105 MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-5308
Mailing Address - Country:US
Mailing Address - Phone:716-692-6388
Mailing Address - Fax:716-692-1227
Practice Address - Street 1:105 MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-5308
Practice Address - Country:US
Practice Address - Phone:716-692-6388
Practice Address - Fax:716-692-1227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-26
Last Update Date:2012-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17364-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC 1358Medicare UPIN