Provider Demographics
NPI:1275333569
Name:PEACOCK AUTISM
Entity type:Organization
Organization Name:PEACOCK AUTISM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:POONAM
Authorized Official - Middle Name:
Authorized Official - Last Name:NANDAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-306-4395
Mailing Address - Street 1:6818 FORDCREST RD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-2187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6818 FORDCREST RD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-2187
Practice Address - Country:US
Practice Address - Phone:443-636-6003
Practice Address - Fax:443-684-2809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-15
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty