Provider Demographics
NPI:1366804296
Name:PEACOCK, SUSAN LISA (MS, MPA-HSA,)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LISA
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:MS, MPA-HSA,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4293 CUTTING HORSE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89519
Mailing Address - Country:US
Mailing Address - Phone:775-787-7261
Mailing Address - Fax:
Practice Address - Street 1:4293 CUTTING HORSE CIRCLE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89519
Practice Address - Country:US
Practice Address - Phone:775-787-7261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-21
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6540235Z00000X
TX104216235Z00000X
VA2202006168235Z00000X
NVSP-143235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist