Provider Demographics
NPI:1730379462
Name:PEACOCK, M CHARLENE (LBSW)
Entity type:Individual
Prefix:
First Name:M
Middle Name:CHARLENE
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 CLINTON PARKWAY CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-2627
Mailing Address - Country:US
Mailing Address - Phone:785-843-5483
Mailing Address - Fax:
Practice Address - Street 1:3205 CLINTON PARKWAY CT
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-2627
Practice Address - Country:US
Practice Address - Phone:785-843-5483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
KS6687104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker