Provider Demographics
NPI:1720139165
Name:PEACOCK, CAROL (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 FERN ST
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02466-2207
Mailing Address - Country:US
Mailing Address - Phone:617-547-6200
Mailing Address - Fax:617-547-4884
Practice Address - Street 1:158 MOUNT AUBURN ST
Practice Address - Street 2:STE 2
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4876
Practice Address - Country:US
Practice Address - Phone:617-547-6200
Practice Address - Fax:617-527-3288
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3952103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPEWO3936Medicare ID - Type Unspecified