Provider Demographics
NPI:1316189566
Name:PECK, KELLY (MPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PECK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:27023 TIMBERLINE TER
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91381-0623
Mailing Address - Country:US
Mailing Address - Phone:213-309-5767
Mailing Address - Fax:
Practice Address - Street 1:1835 S SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-4313
Practice Address - Country:US
Practice Address - Phone:310-478-6222
Practice Address - Fax:310-478-6696
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT220972251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT22097OtherCA PHYSICAL THERAPY LICENSE