Provider Demographics
NPI:1225505803
Name:PEACOCK, MICHELLE A (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:A
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 W PUTNAM AVE STE 2682
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-5203
Mailing Address - Country:US
Mailing Address - Phone:203-742-0500
Mailing Address - Fax:
Practice Address - Street 1:57 OLD POST RD NO 2 STE 206
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6786
Practice Address - Country:US
Practice Address - Phone:203-742-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003726103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003726OtherLICENSE