Healthcare Provider Details

I. General information

NPI: 1528099892
Provider Name (Legal Business Name): JOHN W. GEORGE LCSW, SWL,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 05/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 MICHIGAN AVE
LOGANSPORT IN
46947-1526
US

IV. Provider business mailing address

1015 MICHIGAN AVE
LOGANSPORT IN
46947-1526
US

V. Phone/Fax

Practice location:
  • Phone: 574-722-5151
  • Fax: 574-739-1414
Mailing address:
  • Phone: 574-722-5151
  • Fax: 574-739-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33000266A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35000286A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34000629A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: