MEDICARE: MR. BRYAN JAMES PEACOCK L.P.C.

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	101YP2500X	Professional Counselor	3957-125	WI

General Provider Information

NPI Number	:	1780819797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRYAN JAMES PEACOCK L.P.C.

Provider Business Mailing Address
First Line	:	N67W24937 STONEGATE CT
Second Line	:	#203
City	:	SUSSEX
State	:	WI
Zip	:	53089-2585
Country	:	US
Telephone Number	:	414-840-7247
Fax Number	:

Provider Business Practice Location Address
First Line	:	11904 W NORTH AVE
Second Line	:	SUITE # 110
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-2062
Country	:	US
Telephone Number	:	414-248-4347
Fax Number	:

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

Provider Enumeration Date	:	05/19/2009
Last Update Date	:	05/19/2009

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