Healthcare Provider Details

I. General information

NPI: 1609978709
Provider Name (Legal Business Name): SHARON ANN PEACOCK MED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHARIE ANN PEACOCK MED

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 MAIN ST
OLD TOWN ME
04468-2022
US

IV. Provider business mailing address

1169 MAIN ST
OLD TOWN ME
04468-2022
US

V. Phone/Fax

Practice location:
  • Phone: 207-827-7878
  • Fax: 207-827-6900
Mailing address:
  • Phone: 207-827-7878
  • Fax: 207-827-6900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC981
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: