Provider Demographics
NPI:1265888598
Name:PECK, CARL
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:
Last Name:PECK
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ANDY
Other - Middle Name:
Other - Last Name:PECK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:3525 COUNTRY ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4485 TENCH RD
Practice Address - Street 2:SUITE 1020
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6739
Practice Address - Country:US
Practice Address - Phone:678-697-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005748101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional