Basic Information
| Provider Information | |||||||||
| NPI: | 1568515013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOONEY | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 58609 | ||||||||
| Address2: | |||||||||
| City: | SLC | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841580609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012133800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 N MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SLC | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015812268 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 117185-2501 | UT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | D4417 | 05 | UT | MEDICAID |