Provider Demographics
NPI:1861258709
Name:PEACOCK, AMBER
Entity type:Individual
Prefix:MS
First Name:AMBER
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4114 W BELLA BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-1920
Mailing Address - Country:US
Mailing Address - Phone:801-694-4491
Mailing Address - Fax:
Practice Address - Street 1:3855 S 700 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1157
Practice Address - Country:US
Practice Address - Phone:801-268-4766
Practice Address - Fax:801-262-2145
Is Sole Proprietor?:No
Enumeration Date:2024-02-27
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5848356-4003225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist