Provider Demographics
NPI:1053916965
Name:PEACOCK, REGINA JOANNA (LCSW)
Entity type:Individual
Prefix:MISS
First Name:REGINA
Middle Name:JOANNA
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:REGINA
Other - Middle Name:J
Other - Last Name:PEACOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:16195 SISKIYOU RD STE 120B
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1346
Mailing Address - Country:US
Mailing Address - Phone:760-646-9766
Mailing Address - Fax:760-646-9765
Practice Address - Street 1:5822 OLIVE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92377-3964
Practice Address - Country:US
Practice Address - Phone:909-831-0446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA983031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical