Healthcare Provider Details

I. General information

NPI: 1982292645
Provider Name (Legal Business Name): GEORGE GIFFORD IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1248
SWAINSBORO GA
30401-1248
US

IV. Provider business mailing address

PO BOX 1248
SWAINSBORO GA
30401-1248
US

V. Phone/Fax

Practice location:
  • Phone: 502-554-3554
  • Fax:
Mailing address:
  • Phone: 502-554-3554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMHC10001844
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: