Provider Demographics
NPI:1922365980
Name:PECK, MELODY J (LCT, SDNM)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:J
Last Name:PECK
Suffix:
Gender:F
Credentials:LCT, SDNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 KEYSTONE CT
Mailing Address - Street 2:
Mailing Address - City:LEOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17540-2207
Mailing Address - Country:US
Mailing Address - Phone:717-556-8103
Mailing Address - Fax:888-496-6297
Practice Address - Street 1:12 KEYSTONE CT
Practice Address - Street 2:
Practice Address - City:LEOLA
Practice Address - State:PA
Practice Address - Zip Code:17540-2207
Practice Address - Country:US
Practice Address - Phone:717-556-8103
Practice Address - Fax:888-496-6297
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAL511857133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist