Provider Demographics
NPI:1609599711
Name:BACON, GEORGE ALBERT JR (LCMHCS, LCAS)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:ALBERT
Last Name:BACON
Suffix:JR
Gender:M
Credentials:LCMHCS, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 SEAGRAVE DR
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-0119
Mailing Address - Country:US
Mailing Address - Phone:252-341-2761
Mailing Address - Fax:
Practice Address - Street 1:2201 SEAGRAVE DR
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-0119
Practice Address - Country:US
Practice Address - Phone:252-341-2761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-22
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCS9005101Y00000X
NCLCAS-2748101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)