Provider Demographics
NPI:1801438106
Name:PECK, ELIZABETH ROSE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ROSE
Last Name:PECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLIE
Other - Middle Name:ROSE
Other - Last Name:THERAPY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:400 E EVERGREEN BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3263
Mailing Address - Country:US
Mailing Address - Phone:360-935-0644
Mailing Address - Fax:
Practice Address - Street 1:400 E EVERGREEN BLVD STE 102
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3263
Practice Address - Country:US
Practice Address - Phone:360-935-0644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61069022101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health