Provider Demographics
NPI:1578678173
Name:PECHE, LEROY L (MSW)
Entity Type:Individual
Prefix:MR
First Name:LEROY
Middle Name:L
Last Name:PECHE
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1641 W RIVER OAKS LN
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-2638
Mailing Address - Country:US
Mailing Address - Phone:262-243-5679
Mailing Address - Fax:
Practice Address - Street 1:10850 W PARK PL
Practice Address - Street 2:SUITE 100
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-3606
Practice Address - Country:US
Practice Address - Phone:262-542-3255
Practice Address - Fax:414-359-1021
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI696-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39274500Medicaid