Provider Demographics
NPI:1720181118
Name:PECK, SANDRA GRAHAM (EDM RD)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:GRAHAM
Last Name:PECK
Suffix:
Gender:F
Credentials:EDM RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 GREAT ROAD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720
Mailing Address - Country:US
Mailing Address - Phone:978-266-1576
Mailing Address - Fax:
Practice Address - Street 1:481 GREAT ROAD
Practice Address - Street 2:SUITE 10
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720
Practice Address - Country:US
Practice Address - Phone:978-266-1576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA39477OtherHARVARD PILGRIM
MA467468OtherTUFTS
MALD0016OtherBLUE CROSS BLUE SHIELD
MA467468OtherTUFTS