Healthcare Provider Details

I. General information

NPI: 1134228612
Provider Name (Legal Business Name): DWAYNE F GEORGE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 12/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 MYERS ST 2ND FLOOR
RIVERSIDE CA
92503-3505
US

IV. Provider business mailing address

3840 MYERS ST 2ND FLOOR
RIVERSIDE CA
92503-3614
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4850
  • Fax: 951-358-4852
Mailing address:
  • Phone: 951-358-4850
  • Fax: 951-358-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS19854
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: