Provider Demographics
NPI:1912346271
Name:DAVIS PECK, LISA M (LMHC, LMFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DAVIS PECK
Suffix:
Gender:F
Credentials:LMHC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6644 GREENDALE LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-1068
Mailing Address - Country:US
Mailing Address - Phone:317-919-8482
Mailing Address - Fax:317-203-0983
Practice Address - Street 1:24 S LYNHURST DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-1230
Practice Address - Country:US
Practice Address - Phone:317-919-8482
Practice Address - Fax:317-203-0983
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001460A101YA0400X
IN39001382A101YM0800X
IN35001131A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist