Provider Demographics
NPI:1275854267
Name:PEACOCK, KELLEY PERKINS
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:PERKINS
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 WEYBURN DR NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-3414
Mailing Address - Country:US
Mailing Address - Phone:980-621-8380
Mailing Address - Fax:
Practice Address - Street 1:553 WEYBURN DR NW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-3414
Practice Address - Country:US
Practice Address - Phone:980-621-8380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4725101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool