Provider Demographics
NPI:1093516577
Name:PEACOCK, STEPHEN WALLACE
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WALLACE
Last Name:PEACOCK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 RICHMOND WALK DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-6921
Mailing Address - Country:US
Mailing Address - Phone:912-321-7907
Mailing Address - Fax:
Practice Address - Street 1:2040 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2226
Practice Address - Country:US
Practice Address - Phone:912-354-2752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-21
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003459225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant