Provider Demographics
NPI:1497154280
Name:PECK, TAYLER (COTA)
Entity Type:Individual
Prefix:
First Name:TAYLER
Middle Name:
Last Name:PECK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:878 BROOKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-5039
Mailing Address - Country:US
Mailing Address - Phone:208-406-7799
Mailing Address - Fax:
Practice Address - Street 1:7 N 600 W
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-5533
Practice Address - Country:US
Practice Address - Phone:208-782-2267
Practice Address - Fax:208-684-9812
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTAL-1363224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant