Provider Demographics
NPI:1295761518
Name:PECK, KERRY ANN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KERRY
Middle Name:ANN
Last Name:PECK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KERRY
Other - Middle Name:ANN
Other - Last Name:DUCOURANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSW
Mailing Address - Street 1:10236 WILLOW BANK CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4210
Mailing Address - Country:US
Mailing Address - Phone:801-572-8936
Mailing Address - Fax:
Practice Address - Street 1:10236 WILLOW BANK CIR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4210
Practice Address - Country:US
Practice Address - Phone:801-572-8936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT32106535011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical