Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106E00000X | Assistant Behavior Analyst |
NPI | 1124519228 |
---|---|
Provider Name | Mariah Peck |
First Address | Suffield, CT 06078-2224 |
Second Address | Springfield, MA 01108-1046 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2018 |
Last Update Date | 23/05/2018 |