Provider Demographics
NPI:1861697062
Name:PECK, REGINA SUE (LPC)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:SUE
Last Name:PECK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:SUE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:23610 WOLF VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WISTER
Mailing Address - State:OK
Mailing Address - Zip Code:74966-2945
Mailing Address - Country:US
Mailing Address - Phone:918-647-1924
Mailing Address - Fax:
Practice Address - Street 1:23610 WOLF VALLEY RD
Practice Address - Street 2:
Practice Address - City:WISTER
Practice Address - State:OK
Practice Address - Zip Code:74966-2945
Practice Address - Country:US
Practice Address - Phone:918-647-1924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OK6716101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor