Provider Demographics
NPI:1013423367
Name:PECKHAM, TYLER MATTHEW
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:MATTHEW
Last Name:PECKHAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 W ROSS ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-3931
Mailing Address - Country:US
Mailing Address - Phone:937-216-9282
Mailing Address - Fax:
Practice Address - Street 1:3359 KEMP RD STE 200
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2567
Practice Address - Country:US
Practice Address - Phone:937-490-2090
Practice Address - Fax:937-490-2780
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-22
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHE.2505064101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator