Provider Demographics
NPI:1710929856
Name:PECK, MARTI ELLEN (MARTI PECK, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTI
Middle Name:ELLEN
Last Name:PECK
Suffix:
Gender:F
Credentials:MARTI PECK, PHD
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:ELLEN
Other - Last Name:PECK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2251 SAN DIEGO AVE
Mailing Address - Street 2:SUITE B253
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-2926
Mailing Address - Country:US
Mailing Address - Phone:619-291-9164
Mailing Address - Fax:619-291-9953
Practice Address - Street 1:2251 SAN DIEGO AVE
Practice Address - Street 2:SUITE B253
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2926
Practice Address - Country:US
Practice Address - Phone:619-291-9164
Practice Address - Fax:619-291-9953
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12131103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMPCP12131Medicare ID - Type UnspecifiedPSYCHOLOGIST