Provider Demographics
NPI:1639675184
Name:MOREDOCK, GEORGE E III (LPN)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:E
Last Name:MOREDOCK
Suffix:III
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2848 N TAYLOR LN
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5870
Mailing Address - Country:US
Mailing Address - Phone:520-213-6722
Mailing Address - Fax:
Practice Address - Street 1:2848 N TAYLOR LN
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5870
Practice Address - Country:US
Practice Address - Phone:520-213-6722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC16741101Y00000X, 101YP2500X, 106H00000X, 101YM0800X
AZLPC167741101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist