Healthcare Provider Details

I. General information

NPI: 1689762908
Provider Name (Legal Business Name): FRED GEORGE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 JAMES DR SUITE A
ENTERPRISE AL
36330-2063
US

IV. Provider business mailing address

PO BOX 311062
ENTERPRISE AL
36331-1062
US

V. Phone/Fax

Practice location:
  • Phone: 334-347-1862
  • Fax: 334-308-1942
Mailing address:
  • Phone: 334-347-1862
  • Fax: 334-308-1942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number143
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: