Provider Demographics
NPI:1285644625
Name:PECK, SHERRY L (LPC, ATR)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:L
Last Name:PECK
Suffix:
Gender:F
Credentials:LPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1813
Mailing Address - Country:US
Mailing Address - Phone:262-284-8200
Mailing Address - Fax:262-284-8104
Practice Address - Street 1:121 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1813
Practice Address - Country:US
Practice Address - Phone:262-284-8200
Practice Address - Fax:262-284-8104
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3488101Y00000X
WI3488-125101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40976900Medicaid
WI40976900Medicaid