Provider Demographics
NPI:1134572308
Name:LISA DAVIS PECK
Entity type:Organization
Organization Name:LISA DAVIS PECK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARCELLA
Authorized Official - Last Name:DAVIS PECK
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, LMFT, LCAC
Authorized Official - Phone:317-919-8482
Mailing Address - Street 1:6644 GREENDALE LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-1068
Mailing Address - Country:US
Mailing Address - Phone:317-919-8482
Mailing Address - Fax:
Practice Address - Street 1:6644 GREENDALE LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-1068
Practice Address - Country:US
Practice Address - Phone:317-919-8482
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001382A101YM0800X
IN35001131A106H00000X
87001460A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty