1063533842 NPI number — MR. GEORGE WALLACE HEARNE LCSW

Table of content: MR. GEORGE WALLACE HEARNE LCSW (NPI 1063533842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063533842 NPI number — MR. GEORGE WALLACE HEARNE LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEARNE
Provider First Name:
GEORGE
Provider Middle Name:
WALLACE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063533842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3517 MARCONI AVE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95821-5328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-482-3070
Provider Business Mailing Address Fax Number:
916-482-3070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3517 MARCONI AVE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95821-5328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-482-3070
Provider Business Practice Location Address Fax Number:
916-482-3070
Provider Enumeration Date:
04/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCS 13333 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 112764 UBS . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 7479110 . This is a "AETNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 049741 . This is a "MHN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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