Provider Demographics
NPI:1437704327
Name:PECK, KELSEA DANIELLE (LMSW)
Entity Type:Individual
Prefix:
First Name:KELSEA
Middle Name:DANIELLE
Last Name:PECK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:KELSEA
Other - Middle Name:DANIELLE
Other - Last Name:BUCHANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3530 STEFFISBURG DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-8358
Mailing Address - Country:US
Mailing Address - Phone:480-529-6034
Mailing Address - Fax:
Practice Address - Street 1:1150 BALL AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5901
Practice Address - Country:US
Practice Address - Phone:616-456-6571
Practice Address - Fax:616-235-0979
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MI68011122841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker