Provider Demographics
NPI:1700826765
Name:GEORGE, DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GEORGE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S BROAD ST
Mailing Address - Street 2:STE 234
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130
Mailing Address - Country:US
Mailing Address - Phone:740-654-8716
Mailing Address - Fax:740-653-9252
Practice Address - Street 1:123 S BROAD ST
Practice Address - Street 2:STE 234
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130
Practice Address - Country:US
Practice Address - Phone:740-654-8716
Practice Address - Fax:740-653-9252
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5328103T00000X, 103TA0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGECP21332Medicare ID - Type Unspecified