Provider Demographics
NPI:1356993562
Name:GASTON, GEORGE BYRON
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:BYRON
Last Name:GASTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 ELM ST
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-2707
Mailing Address - Country:US
Mailing Address - Phone:740-374-8967
Mailing Address - Fax:
Practice Address - Street 1:800 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:OH
Practice Address - Zip Code:43758-9019
Practice Address - Country:US
Practice Address - Phone:304-916-8468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA170928101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)