Provider Demographics
NPI:1780467100
Name:PECK, CYNTHIA JEAN
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:JEAN
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 1:16048 NW CENTINE LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-1129
Mailing Address - Country:US
Mailing Address - Phone:503-804-9708
Mailing Address - Fax:
Practice Address - Street 1:15850 NW CENTRAL DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-1101
Practice Address - Country:US
Practice Address - Phone:503-506-2426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR015428235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist