Provider Demographics
NPI:1407079361
Name:WITHERS PH.D., GEORGE H (PHD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:H
Last Name:WITHERS PH.D.
Suffix:
Gender:M
Credentials:PHD
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 302643
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-0045
Mailing Address - Country:US
Mailing Address - Phone:512-459-6000
Mailing Address - Fax:
Practice Address - Street 1:4400 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3314
Practice Address - Country:US
Practice Address - Phone:512-459-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YP2500X, 103T00000X, 103TA0700X, 103TF0000X
TX22835103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102985203Medicaid
TX680013958OtherRR MEDICARE NUMBER
TXTXB110198Medicare PIN
TX102985203Medicaid