Healthcare Provider Details

I. General information

NPI: 1487048070
Provider Name (Legal Business Name): DOUGLAS ULYSSES GEORGE ASW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 SENTINEL DR SUITE 200
LA VERNE CA
91750-3280
US

IV. Provider business mailing address

1540 VIA BUENA
LA VERNE CA
91750-2052
US

V. Phone/Fax

Practice location:
  • Phone: 909-833-2986
  • Fax: 909-833-2998
Mailing address:
  • Phone: 909-706-7288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW65434
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number93830
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: