Provider Demographics
NPI:1598548588
Name:PEACOCK, PEACHES MARIE
Entity Type:Individual
Prefix:
First Name:PEACHES
Middle Name:MARIE
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1474 STEPHENS POND VW
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8749
Mailing Address - Country:US
Mailing Address - Phone:757-256-4529
Mailing Address - Fax:
Practice Address - Street 1:1474 STEPHENS POND VW
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8749
Practice Address - Country:US
Practice Address - Phone:175-725-6452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23-285418106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician