Provider Demographics
NPI:1982982153
Name:PECKHAM, KATHERINE L (CNA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:L
Last Name:PECKHAM
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 WEST 4695 SOUTH
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84120
Mailing Address - Country:US
Mailing Address - Phone:801-702-0842
Mailing Address - Fax:
Practice Address - Street 1:4190 W 4695 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84120-6062
Practice Address - Country:US
Practice Address - Phone:801-702-0842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor