Provider Demographics
NPI:1114384815
Name:DAVID E PEACO,PHD,LLC
Entity Type:Organization
Organization Name:DAVID E PEACO,PHD,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:PEACO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:636-332-5050
Mailing Address - Street 1:600 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3426
Mailing Address - Country:US
Mailing Address - Phone:636-332-5050
Mailing Address - Fax:636-327-4723
Practice Address - Street 1:600 MEDICAL DR STE 205
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3426
Practice Address - Country:US
Practice Address - Phone:636-332-5050
Practice Address - Fax:636-327-4723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01175103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO70091Medicare UPIN