Provider Demographics
NPI:1639657315
Name:PECK, LETITIA M (R1306170518 CATC REG)
Entity Type:Individual
Prefix:
First Name:LETITIA
Middle Name:M
Last Name:PECK
Suffix:
Gender:F
Credentials:R1306170518 CATC REG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3043 MACARTHUR DR
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-4763
Mailing Address - Country:US
Mailing Address - Phone:831-582-9461
Mailing Address - Fax:
Practice Address - Street 1:3043 MACARTHUR DR
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-4763
Practice Address - Country:US
Practice Address - Phone:831-582-9461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1306170518101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1306170518OtherCCAPP