Provider Demographics
NPI:1609459916
Name:GAY, GEORGE (CO60917266)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:GAY
Suffix:
Gender:M
Credentials:CO60917266
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 APOLLO ST SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-7135
Mailing Address - Country:US
Mailing Address - Phone:360-522-2088
Mailing Address - Fax:
Practice Address - Street 1:627 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3504
Practice Address - Country:US
Practice Address - Phone:360-763-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)