Healthcare Provider Details

I. General information

NPI: 1720027006
Provider Name (Legal Business Name): GEORGE MARSHALL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 4TH ST
LEWISPORT KY
42351-2526
US

IV. Provider business mailing address

1210 4TH ST
LEWISPORT KY
42351-2526
US

V. Phone/Fax

Practice location:
  • Phone: 270-295-6452
  • Fax: 270-295-6450
Mailing address:
  • Phone: 270-295-6452
  • Fax: 270-295-6450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1636
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: