Provider Demographics
NPI:1689762908
Name:GEORGE, FRED (PHD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:GEORGE
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 311062
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36331-1062
Mailing Address - Country:US
Mailing Address - Phone:334-347-1862
Mailing Address - Fax:334-308-1942
Practice Address - Street 1:1275 JAMES DR
Practice Address - Street 2:SUITE A
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2063
Practice Address - Country:US
Practice Address - Phone:334-347-1862
Practice Address - Fax:334-308-1942
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL143103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL890001970Medicaid
AL51070221Medicare UPIN