Provider Demographics
NPI:1811943830
Name:PECK, EDWARD ARNOLD III (PHD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:ARNOLD
Last Name:PECK
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 BREMO RD
Mailing Address - Street 2:SUITE 127
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2444
Mailing Address - Country:US
Mailing Address - Phone:804-285-2555
Mailing Address - Fax:804-282-0314
Practice Address - Street 1:2010 BREMO RD
Practice Address - Street 2:SUITE 127
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2444
Practice Address - Country:US
Practice Address - Phone:804-285-2555
Practice Address - Fax:804-282-0314
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000910103G00000X, 103TC0700X
MA2228103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007705948Medicaid
VA018091OtherANTHEM BCBS
VA087976OtherSENTARA MENTAL HEALTH
VA018091OtherANTHEM BCBS
VA087976OtherSENTARA MENTAL HEALTH