Provider Demographics
NPI:1811713753
Name:PEABODY, CHRISTIAN W
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:W
Last Name:PEABODY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 SAN FELIPE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-1707
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:866-611-1558
Practice Address - Street 1:17235 N 75TH AVE STE G120
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-0895
Practice Address - Country:US
Practice Address - Phone:480-812-4789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician