Provider Demographics
NPI:1871597286
Name:PEAVY, TAMI (PT)
Entity type:Individual
Prefix:
First Name:TAMI
Middle Name:
Last Name:PEAVY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 W ALAMEDA AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-2929
Mailing Address - Country:US
Mailing Address - Phone:706-306-3641
Mailing Address - Fax:818-861-7348
Practice Address - Street 1:320 W VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-3338
Practice Address - Country:US
Practice Address - Phone:706-306-3641
Practice Address - Fax:818-861-7348
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA73472251P0200X
CA33736225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000937329DMedicaid
GA000937329DMedicaid
CABM991AMedicare PIN