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General NPI Number Information
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NPI Number | 1780819797
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Entity Type | Individual
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Provider Name | BRYAN JAMES PEACOCK L.P.C.
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Gender | Male
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Dates
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Enumeration Date | 05/19/2009
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Last Update Date | 05/19/2009
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Provider Practice Location Address
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Address Line | 11904 W NORTH AVE SUITE # 110
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City | WAUWATOSA
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State | WI
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Zip | 53226-2062
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Country | US
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Telephone | 414-248-4347
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Fax |
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Provider Business Mailing Address
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Address Line | N67W24937 STONEGATE CT #203
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City | SUSSEX
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State | WI
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Zip | 53089-2585
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Country | US
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Telephone | 414-840-7247
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Fax |
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 3957-125
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License Number State | WI
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