Provider Demographics
NPI:1013655232
Name:AFFONSO, GEORGE D (LADC I, CADC)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:D
Last Name:AFFONSO
Suffix:
Gender:M
Credentials:LADC I, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11A STANDISH AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4145
Mailing Address - Country:US
Mailing Address - Phone:501-626-8050
Mailing Address - Fax:
Practice Address - Street 1:60 CHERRY ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4466
Practice Address - Country:US
Practice Address - Phone:508-746-6654
Practice Address - Fax:508-746-2433
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16860101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)