Provider Demographics
NPI:1861536245
Name:PEACOCK, AMY (PT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:MENDON
Mailing Address - State:VT
Mailing Address - Zip Code:05701-9642
Mailing Address - Country:US
Mailing Address - Phone:802-775-1555
Mailing Address - Fax:
Practice Address - Street 1:45 NOTCH RD
Practice Address - Street 2:
Practice Address - City:MENDON
Practice Address - State:VT
Practice Address - Zip Code:05701-9642
Practice Address - Country:US
Practice Address - Phone:802-775-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0002379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist