Provider Demographics
NPI:1457466922
Name:PECK, SHANNON LEA (MS LPC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEA
Last Name:PECK
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:LEA
Other - Last Name:PECK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:5410 FREDERICKSBURG ROAD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3539
Mailing Address - Country:US
Mailing Address - Phone:210-524-9402
Mailing Address - Fax:210-524-9732
Practice Address - Street 1:3030 NACOGDOCHES RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-4502
Practice Address - Country:US
Practice Address - Phone:210-826-9599
Practice Address - Fax:210-826-9828
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13772101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA046244OtherVALUE OPTIONS
TX3479LCOtherBLUE CROSS BLUE SHIELD
TX027879801Medicaid