Provider Demographics
NPI:1679684997
Name:PECKHAM, GEORGE (MFT)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:
Last Name:PECKHAM
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8261 GREENBACK LN # 100
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-2504
Mailing Address - Country:US
Mailing Address - Phone:916-420-6388
Mailing Address - Fax:
Practice Address - Street 1:8261 GREENBACK LN # 100
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-2504
Practice Address - Country:US
Practice Address - Phone:916-420-6388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT47127106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist