Provider Demographics
NPI:1902061997
Name:PEABODY, CAROLYN GRACE (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:GRACE
Last Name:PEABODY
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 GREENWAY E
Mailing Address - Street 2:
Mailing Address - City:ORIENT
Mailing Address - State:NY
Mailing Address - Zip Code:11957-1314
Mailing Address - Country:US
Mailing Address - Phone:631-323-1333
Mailing Address - Fax:631-323-3824
Practice Address - Street 1:53840 MAIN RD
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-4625
Practice Address - Country:US
Practice Address - Phone:631-323-1333
Practice Address - Fax:631-323-3824
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-19
Last Update Date:2008-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR038969-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical