Healthcare Provider Details

I. General information

NPI: 1427765593
Provider Name (Legal Business Name): RENEE PEACOCK MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2022
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 GALLBERRY LN
WAXHAW NC
28173-0161
US

IV. Provider business mailing address

2041 WHITE CEDAR LN
WAXHAW NC
28173-8088
US

V. Phone/Fax

Practice location:
  • Phone: 704-649-4509
  • Fax:
Mailing address:
  • Phone: 828-713-3118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number15532
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number15532
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: