Provider Demographics
NPI:1013472463
Name:PECK, KENNETH DAVID
Entity Type:Individual
Prefix:
First Name:KENNETH DAVID
Middle Name:
Last Name:PECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 DATE ST APT 204
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-4019
Mailing Address - Country:US
Mailing Address - Phone:808-230-6130
Mailing Address - Fax:
Practice Address - Street 1:2100 DATE ST APT 204
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-4019
Practice Address - Country:US
Practice Address - Phone:808-230-6130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician