Provider Demographics
NPI:1437616257
Name:MICHELLE PEACOCK PHD LLC
Entity Type:Organization
Organization Name:MICHELLE PEACOCK PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE PROPRIETOR/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:203-609-3602
Mailing Address - Street 1:177 W. PUTNAM AVE.
Mailing Address - Street 2:SUITE 2682
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 1:177 W. PUTNAM AVE.
Practice Address - Street 2:SUITE 2682
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-5203
Practice Address - Country:US
Practice Address - Phone:203-742-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-28
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)