Provider Demographics
NPI:1144690363
Name:PEEK, MARDOSHA
Entity type:Individual
Prefix:
First Name:MARDOSHA
Middle Name:
Last Name:PEEK
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 1:3307 SALEM PL
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-3156
Mailing Address - Country:US
Mailing Address - Phone:318-393-5407
Mailing Address - Fax:
Practice Address - Street 1:3307 SALEM PL
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-3156
Practice Address - Country:US
Practice Address - Phone:318-393-5407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health