Provider Demographics
NPI:1619465317
Name:TAY, GEORGE WALTON JR (RADT-1)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:WALTON
Last Name:TAY
Suffix:JR
Gender:M
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2068
Mailing Address - Country:US
Mailing Address - Phone:951-823-0540
Mailing Address - Fax:
Practice Address - Street 1:1660 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2068
Practice Address - Country:US
Practice Address - Phone:951-823-0540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1291540218101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)