Provider Demographics
NPI:1396841565
Name:DE ROECK, GEORGE M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:M
Last Name:DE ROECK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 W MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-2741
Mailing Address - Country:US
Mailing Address - Phone:870-972-4770
Mailing Address - Fax:870-972-4774
Practice Address - Street 1:308 W MONROE AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-2741
Practice Address - Country:US
Practice Address - Phone:870-972-4770
Practice Address - Fax:870-972-4774
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR84-7P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56094Medicare UPIN