Provider Demographics
NPI:1538805247
Name:PECKHAM, MICHELLE DIANE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANE
Last Name:PECKHAM
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 1:4319 N BARTON CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-4229
Mailing Address - Country:US
Mailing Address - Phone:316-214-9879
Mailing Address - Fax:
Practice Address - Street 1:8080 E CENTRAL AVE STE 320
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2389
Practice Address - Country:US
Practice Address - Phone:316-927-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3581101YM0800X
KS03848101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health