Provider Demographics
NPI:1417444621
Name:PECKETT, GEORGIA J
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:J
Last Name:PECKETT
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 1:321 SWEETWATER SPRINGS ST
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-4819
Mailing Address - Country:US
Mailing Address - Phone:321-710-6313
Mailing Address - Fax:
Practice Address - Street 1:1209 E 2ND ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1413
Practice Address - Country:US
Practice Address - Phone:407-792-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH15220101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health