Provider Demographics
NPI:1255650628
Name:PECK, CATHY ANN (COTA)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:ANN
Last Name:PECK
Suffix:
Gender:F
Credentials:COTA
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 1994
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402-1994
Mailing Address - Country:US
Mailing Address - Phone:573-308-6248
Mailing Address - Fax:
Practice Address - Street 1:810 JOE BROOKS DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4133
Practice Address - Country:US
Practice Address - Phone:870-931-6789
Practice Address - Fax:870-931-4363
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A603224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1659437945Medicaid