Provider Demographics
NPI:1376184101
Name:PECZKA, KELLY HASKELL
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:HASKELL
Last Name:PECZKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 DINGLER RD
Mailing Address - Street 2:
Mailing Address - City:MORELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30259-2229
Mailing Address - Country:US
Mailing Address - Phone:413-250-7848
Mailing Address - Fax:
Practice Address - Street 1:500 LANIER AVE W STE 702
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7643
Practice Address - Country:US
Practice Address - Phone:413-250-7848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009203225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist