Healthcare Provider Details

I. General information

NPI: 1538613948
Provider Name (Legal Business Name): MICHAEL JAMES PEACOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E F ST
TEHACHAPI CA
93561-1710
US

IV. Provider business mailing address

113 E F ST
TEHACHAPI CA
93561-1710
US

V. Phone/Fax

Practice location:
  • Phone: 661-822-8223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301016803
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: