Provider Demographics
NPI:1871600825
Name:PEACOCK, LARRY DEAN (LPC, CSAC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:DEAN
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6614 CUSTER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-1501
Mailing Address - Country:US
Mailing Address - Phone:703-922-6544
Mailing Address - Fax:
Practice Address - Street 1:4213 WALNEY RD
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-2923
Practice Address - Country:US
Practice Address - Phone:703-502-7039
Practice Address - Fax:703-502-7055
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003461101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional