Provider Demographics
NPI:1821211095
Name:KELLY-PECK, COLLEEN MARY (MC)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:MARY
Last Name:KELLY-PECK
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 E WARNER RD
Mailing Address - Street 2:105-127
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3437
Mailing Address - Country:US
Mailing Address - Phone:480-775-7400
Mailing Address - Fax:480-775-7406
Practice Address - Street 1:2111 E BASELINE RD
Practice Address - Street 2:SUITE A-4
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1516
Practice Address - Country:US
Practice Address - Phone:480-775-7400
Practice Address - Fax:480-775-7406
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-0541101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health