Provider Demographics
NPI:1861881880
Name:PECK, ANGELA T (LAC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:T
Last Name:PECK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:T
Other - Last Name:PECK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:521 N MAIN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-5948
Mailing Address - Country:US
Mailing Address - Phone:605-367-8793
Mailing Address - Fax:605-367-8247
Practice Address - Street 1:521 N MAIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-5948
Practice Address - Country:US
Practice Address - Phone:605-367-8793
Practice Address - Fax:605-367-8247
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD08051364101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)