Provider Demographics
NPI:1457570277
Name:PEACOCK, ROBIN ROSS (LSAC)
Entity Type:Individual
Prefix:MR
First Name:ROBIN
Middle Name:ROSS
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:LSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5961 W 5050 S
Mailing Address - Street 2:
Mailing Address - City:HOOPER
Mailing Address - State:UT
Mailing Address - Zip Code:84315-9720
Mailing Address - Country:US
Mailing Address - Phone:801-985-9891
Mailing Address - Fax:801-621-4203
Practice Address - Street 1:2127 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1313
Practice Address - Country:US
Practice Address - Phone:801-625-3686
Practice Address - Fax:801-621-4203
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT138819-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000308007Medicaid