MEDICARE: SANDRA PEACOCK MS, CGC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1629457148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA PEACOCK MS, CGC

Provider Business Mailing Address
First Line	:	2450 HOLCOMBE BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021-2039
Country	:	US
Telephone Number	:	713-798-7651
Fax Number	:	713-798-2787

Provider Business Practice Location Address
First Line	:	2450 HOLCOMBE BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021-2039
Country	:	US
Telephone Number	:	713-798-7651
Fax Number	:	713-798-2787

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2015
Last Update Date	:	05/29/2015

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