Provider Demographics
NPI:1144306218
Name:PEABODY, TOM (PHD)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:PEABODY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 LORTON AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-4133
Mailing Address - Country:US
Mailing Address - Phone:650-634-9807
Mailing Address - Fax:650-348-3087
Practice Address - Street 1:345 LORTON AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4133
Practice Address - Country:US
Practice Address - Phone:650-634-9807
Practice Address - Fax:650-348-3087
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15343103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY153430Medicaid
CAPSY153430Medicaid
CA01682104Medicare UPIN