Provider Demographics
NPI:1861889206
Name:PECKHAM, KYLE J (ATC)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:J
Last Name:PECKHAM
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-3073
Mailing Address - Country:US
Mailing Address - Phone:802-734-6364
Mailing Address - Fax:
Practice Address - Street 1:10 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-3073
Practice Address - Country:US
Practice Address - Phone:802-734-6364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-23
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program