MEDICARE: MR. BRANDON JAMES PEACOCK MA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-19-87690	AZ
2	103K00000X	Behavior Analyst	BEH-001377	AZ

General Provider Information

NPI Number	:	1528734753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRANDON JAMES PEACOCK MA

Provider Business Mailing Address
First Line	:	1718 E SPEEDWAY BLVD # 4177
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85719-4515
Country	:	US
Telephone Number	:	520-222-6538
Fax Number	:

Provider Business Practice Location Address
First Line	:	1718 E SPEEDWAY BLVD # 4177
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85719-4515
Country	:	US
Telephone Number	:	520-222-6538
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2021
Last Update Date	:	08/05/2024

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