Provider Demographics
NPI:1467992461
Name:PEACOCK, REBECCA LEIGH (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEIGH
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 PARKSIDE TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2950
Mailing Address - Country:US
Mailing Address - Phone:517-449-6758
Mailing Address - Fax:
Practice Address - Street 1:810 TYVOLA RD STE 126
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-3536
Practice Address - Country:US
Practice Address - Phone:704-566-3410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0115531041C0700X
NY0911641041C0700X
NCC0151591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical