Provider Demographics
NPI:1578795399
Name:PEACOCK, KRISTA LYNN (LMSW)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:LYNN
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 BYRON WAY
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-2257
Mailing Address - Country:US
Mailing Address - Phone:631-567-2584
Mailing Address - Fax:
Practice Address - Street 1:74 BYRON WAY
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-2257
Practice Address - Country:US
Practice Address - Phone:631-567-2584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060503-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker