Healthcare Provider Details

I. General information

NPI: 1548617855
Provider Name (Legal Business Name): JAMIE JOHN DEGEORGE LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 W HUMBOLDT PKWY
BUFFALO NY
14214-2604
US

IV. Provider business mailing address

95 W HUMBOLDT PKWY
BUFFALO NY
14214-2604
US

V. Phone/Fax

Practice location:
  • Phone: 716-710-5151
  • Fax: 716-883-0687
Mailing address:
  • Phone: 716-710-5151
  • Fax: 716-883-0687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001811-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001811
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: