Provider Demographics
NPI:1467993378
Name:PECK, JOHNNIE
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:
Last Name:PECK
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 1:24624 INTERSTATE 45 N
Mailing Address - Street 2:#200
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-4084
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24624 INTERSTATE 45 N
Practice Address - Street 2:#200
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-4084
Practice Address - Country:US
Practice Address - Phone:832-799-4954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX05115620Medicaid