Provider Demographics
NPI:1114284619
Name:PEACOCK, AMI MARIE (LISW-S)
Entity Type:Individual
Prefix:
First Name:AMI
Middle Name:MARIE
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 LANE ON THE LK
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-7580
Mailing Address - Country:US
Mailing Address - Phone:216-408-9497
Mailing Address - Fax:
Practice Address - Street 1:921 CHATHAM LN STE 112
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2418
Practice Address - Country:US
Practice Address - Phone:614-754-7648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0009629104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker