Provider Demographics
NPI:1023418704
Name:GEORGE, CHRISTOPHER DEREK (LBCBA)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DEREK
Last Name:GEORGE
Suffix:
Gender:M
Credentials:LBCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 OBSERVATION POINTE DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3784
Mailing Address - Country:US
Mailing Address - Phone:606-875-2137
Mailing Address - Fax:
Practice Address - Street 1:196 OBSERVATION POINTE DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3784
Practice Address - Country:US
Practice Address - Phone:606-875-2137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0013103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100323050Medicaid