Basic Information
| Provider Information | |||||||||
| NPI: | 1912102450 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PECK | ||||||||
| FirstName: | KYLA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | MS, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013236000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013236000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2007 | ||||||||
| LastUpdateDate: | 10/03/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 984 | ND | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 027842 | 01 | ND | BLUE CROSS BLUE SHIELD | OTHER | 51509 | 05 | ND | MEDICAID |