Provider Demographics
NPI:1467861575
Name:PEACOCK, SCOTT CHARLES (MA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:CHARLES
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9914 WINCHESTER VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77064-3820
Mailing Address - Country:US
Mailing Address - Phone:713-478-5650
Mailing Address - Fax:
Practice Address - Street 1:10330 LAKE RD STE A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-1696
Practice Address - Country:US
Practice Address - Phone:713-478-5650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12382101YA0400X
TX71179101YP2500X
TX202198106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist