Healthcare Provider Details

I. General information

NPI: 1710908819
Provider Name (Legal Business Name): GEORGE MATTHEW WYSOR LCDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 HARROUN AVE
MCKINNEY TX
75069-3432
US

IV. Provider business mailing address

1505 HARROUN AVE
MCKINNEY TX
75069-3432
US

V. Phone/Fax

Practice location:
  • Phone: 972-548-0209
  • Fax: 972-548-0306
Mailing address:
  • Phone: 972-548-0209
  • Fax: 972-548-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8766
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: