Provider Demographics
NPI:1942281969
Name:PEACOCK, COREY A (OT)
Entity Type:Individual
Prefix:MISS
First Name:COREY
Middle Name:A
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59-520 HOALIKE RD
Mailing Address - Street 2:
Mailing Address - City:HALEIWA
Mailing Address - State:HI
Mailing Address - Zip Code:96712-9525
Mailing Address - Country:US
Mailing Address - Phone:808-371-5460
Mailing Address - Fax:
Practice Address - Street 1:95-390 KUAHELANI AVE
Practice Address - Street 2:1C
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-1192
Practice Address - Country:US
Practice Address - Phone:808-445-4428
Practice Address - Fax:866-637-9592
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOT-418225X00000X
HIOT- 418225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN