Provider Demographics
NPI:1821422932
Name:GEORGE, JUVENAL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JUVENAL
Middle Name:
Last Name:GEORGE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 DEVONSHIRE DR.
Mailing Address - Street 2:PO BOX C-3
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820
Mailing Address - Country:US
Mailing Address - Phone:708-381-0445
Mailing Address - Fax:
Practice Address - Street 1:701 DEVONSHIRE DR
Practice Address - Street 2:SUITE 203C BLDG C
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820
Practice Address - Country:US
Practice Address - Phone:708-381-0445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010536103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health