Provider Demographics
NPI:1588795512
Name:PEACOCK, MARY LOU (COTA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOU
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:LOU
Other - Last Name:PERPETUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:4510 HEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6121
Mailing Address - Country:US
Mailing Address - Phone:716-634-6654
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-3949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002010-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant