Healthcare Provider Details

I. General information

NPI: 1770215535
Provider Name (Legal Business Name): DUSTIN E GEORGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9140 S STATE ST STE 201
SANDY UT
84070-2694
US

IV. Provider business mailing address

9140 S STATE ST STE 201
SANDY UT
84070-2694
US

V. Phone/Fax

Practice location:
  • Phone: 385-645-4593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number116635-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13897520-3501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: