Healthcare Provider Details

I. General information

NPI: 1790597151
Provider Name (Legal Business Name): KAILIE GEORGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 SWEET ST NE
GRAND RAPIDS MI
49505-4601
US

IV. Provider business mailing address

3401 DEERING DR
RALEIGH NC
27616-8681
US

V. Phone/Fax

Practice location:
  • Phone: 919-426-0270
  • Fax:
Mailing address:
  • Phone: 919-426-0270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA20213
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: