Provider Demographics
NPI:1609252980
Name:PEABODY, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:PEABODY
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 1:16523 S WATER TOWER DR
Mailing Address - Street 2:
Mailing Address - City:KINCHELOE
Mailing Address - State:MI
Mailing Address - Zip Code:49788-1592
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16523 S WATER TOWER DR
Practice Address - Street 2:
Practice Address - City:KINCHELOE
Practice Address - State:MI
Practice Address - Zip Code:49788-1592
Practice Address - Country:US
Practice Address - Phone:906-495-4387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53012225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist