Provider Demographics
NPI:1427379791
Name:PEISECKI, KENNETH (OT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:PEISECKI
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6802 CHATEAU CHASE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-3940
Mailing Address - Country:US
Mailing Address - Phone:614-352-4680
Mailing Address - Fax:
Practice Address - Street 1:64 DANBURY RD
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-4429
Practice Address - Country:US
Practice Address - Phone:203-800-0332
Practice Address - Fax:800-970-5001
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC011370225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist