Provider Demographics
NPI:1528605763
Name:COLLUCCI, GEORGE LOUIS
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:LOUIS
Last Name:COLLUCCI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41914 50TH ST W
Mailing Address - Street 2:
Mailing Address - City:QUARTZ HILL
Mailing Address - State:CA
Mailing Address - Zip Code:93536-2963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41914 50TH ST W
Practice Address - Street 2:
Practice Address - City:QUARTZ HILL
Practice Address - State:CA
Practice Address - Zip Code:93536-2963
Practice Address - Country:US
Practice Address - Phone:661-722-0716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3380103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool