Provider Demographics
NPI:1700378379
Name:MISSAILIDIS, GEORGE M III
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:M
Last Name:MISSAILIDIS
Suffix:III
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 1:2486 CALLE SAN CLEMENTE
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-6606
Mailing Address - Country:US
Mailing Address - Phone:760-828-8492
Mailing Address - Fax:
Practice Address - Street 1:11650 IBERIA PL STE 130
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2431
Practice Address - Country:US
Practice Address - Phone:909-689-4157
Practice Address - Fax:858-649-6012
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABCBA417447106S00000X
CA1-21-48654103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician