Healthcare Provider Details

I. General information

NPI: 1821422932
Provider Name (Legal Business Name): JUVENAL GEORGE PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DEVONSHIRE DR SUITE 203C BLDG C
CHAMPAIGN IL
61820
US

IV. Provider business mailing address

701 DEVONSHIRE DR. PO BOX C-3
CHAMPAIGN IL
61820
US

V. Phone/Fax

Practice location:
  • Phone: 708-381-0445
  • Fax:
Mailing address:
  • Phone: 708-381-0445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071010536
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: