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1053916965 NPI number — REGINA JOANNA PEACOCK LCSW

NPI Number: 1053916965
Health Care Provider/Practitioner: REGINA JOANNA PEACOCK LCSW

Information about “1053916965” NPI (REGINA JOANNA PEACOCK LCSW) exists in 1053916965 in HTML format HTML  |  1053916965 in plain Text format TXT  |  1053916965 in PDF (Portable Document Format) PDF  |  1053916965 in an XML format XML  formats.

NPI Number : 1053916965 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1053916965",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "PEACOCK",
    "FirstName": "REGINA",
    "MiddleName": "JOANNA",
    "NamePrefix": "MISS",
    "NameSuffix": null,
    "Credential": "LCSW",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "PEACOCK",
    "OtherFirstName": "REGINA",
    "OtherMiddleName": "J",
    "OtherNamePrefix": "MISS",
    "OtherNameSuffix": null,
    "OtherCredential": "LCSW",
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "16195 SISKIYOU RD STE 120B",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "APPLE VALLEY",
    "MailingAddressStateName": "CA",
    "MailingAddressPostalCode": "92307-1346",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "760-646-9766",
    "MailingAddressFaxNumber": "760-646-9765",
    "FirstLinePracticeLocationAddress": "5822 OLIVE AVE",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "RIALTO",
    "PracticeLocationAddressStateName": "CA",
    "PracticeLocationAddressPostalCode": "92377-3964",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "909-831-0446",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "12/01/2020",
    "LastUpdateDate": "08/05/2021",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "1041C0700X",
        "TaxonomyName": "Clinical Social Worker",
        "LicenseNumber": "98303",
        "LicenseNumberStateCode": "CA",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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