Provider Demographics
NPI:1366491334
Name:PECK, LARRY BRAD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:BRAD
Last Name:PECK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3908 S 2175 E
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1718
Mailing Address - Country:US
Mailing Address - Phone:801-647-8010
Mailing Address - Fax:
Practice Address - Street 1:44 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84113-1105
Practice Address - Country:US
Practice Address - Phone:801-584-8533
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT98-351353-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical