Provider Demographics
NPI:1104858695
Name:PEACOCK, GRETCHEN GIMPEL
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:GIMPEL
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 OLD MAIN HL
Mailing Address - Street 2:DEPARTMENT OF PSYCHOLOGY
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-2810
Mailing Address - Country:US
Mailing Address - Phone:435-797-0721
Mailing Address - Fax:435-797-1448
Practice Address - Street 1:2810 OLD MAIN HL
Practice Address - Street 2:DEPARTMENT OF PSYCHOLOGY
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-2810
Practice Address - Country:US
Practice Address - Phone:435-797-0721
Practice Address - Fax:435-797-1448
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT326646-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist