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General NPI Number Information
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NPI Number | 1457570277
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Entity Type | Individual
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Provider Name | ROBIN ROSS PEACOCK LSAC
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Gender | Male
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2127 LINCOLN AVE
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City | OGDEN
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State | UT
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Zip | 84401-1313
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Country | US
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Telephone | 801-625-3686
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Fax | 801-621-4203
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Provider Business Mailing Address
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Address Line | 5961 W 5050 S
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City | HOOPER
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State | UT
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Zip | 84315-9720
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Country | US
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Telephone | 801-985-9891
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Fax | 801-621-4203
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 138819-6006
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License Number State | UT
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