Basic Information
| Provider Information | |||||||||
| NPI: | 1487048070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | ULYSSES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1540 VIA BUENA | ||||||||
| Address2: | |||||||||
| City: | LA VERNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917502052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097067288 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1025 SENTINEL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LA VERNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917503280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098332986 | ||||||||
| FaxNumber: | 9098332998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2015 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | ASW65434 | CA | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 93830 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.