Provider Demographics
NPI:1912297482
Name:PEACOCK, RYAN (OTR)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 MEADOW VIEW DR
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-5070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4714 S COLONIAL OAKS DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-7308
Practice Address - Country:US
Practice Address - Phone:765-674-2261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004681A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist