Provider Demographics
NPI:1205040433
Name:PEACOCK, TAWANNA (LMSW)
Entity Type:Individual
Prefix:
First Name:TAWANNA
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 E 230TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-4103
Mailing Address - Country:US
Mailing Address - Phone:917-405-6086
Mailing Address - Fax:
Practice Address - Street 1:729 E 230TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-4103
Practice Address - Country:US
Practice Address - Phone:917-405-6086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355940OtherAGENCY MEDICAID
NY1285628552OtherAGENCY NPI #
NYWVE061Medicare ID - Type UnspecifiedAGENCY MEDICARE PROVIDER#