Provider Demographics
NPI:1275687378
Name:PECKHAM, TAMI YNETTE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TAMI
Middle Name:YNETTE
Last Name:PECKHAM
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 1:607 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225
Mailing Address - Country:US
Mailing Address - Phone:804-230-4335
Mailing Address - Fax:
Practice Address - Street 1:604 N BOULEVARD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220
Practice Address - Country:US
Practice Address - Phone:804-230-4335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040018381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA074968OtherANTHEM