Provider Demographics
NPI:1780013417
Name:STORER, GEORGE ZACHARY (BCBA)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:ZACHARY
Last Name:STORER
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2519 RYAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7323
Mailing Address - Country:US
Mailing Address - Phone:337-491-0800
Mailing Address - Fax:
Practice Address - Street 1:314 BROAD ST STE B
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-4224
Practice Address - Country:US
Practice Address - Phone:337-491-0805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1-13-14792103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst