Provider Demographics
NPI:1164714606
Name:PEACOCK, GINA VINCENZA (LCSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:VINCENZA
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3043 STATE ROUTE 4
Mailing Address - Street 2:
Mailing Address - City:HUDSON FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12839-9632
Mailing Address - Country:US
Mailing Address - Phone:518-747-2284
Mailing Address - Fax:518-747-2253
Practice Address - Street 1:3043 STATE ROUTE 4
Practice Address - Street 2:
Practice Address - City:HUDSON FALLS
Practice Address - State:NY
Practice Address - Zip Code:12839-9632
Practice Address - Country:US
Practice Address - Phone:518-747-2284
Practice Address - Fax:518-747-2253
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000822391041C0700X
NY000827461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00082746Medicaid
NY00082239Medicaid
NY00082746Medicaid