Provider Demographics
NPI:1578825873
Name:PEACOCK, JULIE ANN (PT DPT BCB PMD)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANN
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:PT DPT BCB PMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2403
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:3020 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5915
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:217-789-2569
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist