Provider Demographics
NPI:1073817557
Name:GEORGE, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:GEORGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2619
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-2619
Mailing Address - Country:US
Mailing Address - Phone:760-924-1740
Mailing Address - Fax:760-924-1741
Practice Address - Street 1:452 OLD MAMMOTH ROAD
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-2619
Practice Address - Country:US
Practice Address - Phone:760-924-1740
Practice Address - Fax:760-924-1741
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-27
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64852101YA0400X
CA82187106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)