Provider Demographics
NPI:1457720260
Name:PECK, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:PECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 6TH ST SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4605
Mailing Address - Country:US
Mailing Address - Phone:863-294-0350
Mailing Address - Fax:863-294-0381
Practice Address - Street 1:1601 6TH ST SE
Practice Address - Street 2:SUITE B
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4605
Practice Address - Country:US
Practice Address - Phone:863-294-0350
Practice Address - Fax:863-294-0381
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 18417261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy