Provider Demographics
NPI:1801350400
Name:MALLINCKRODT, GEORGE
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:MALLINCKRODT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4280 GALT OCEAN DR APT 9C
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-6105
Mailing Address - Country:US
Mailing Address - Phone:305-297-6054
Mailing Address - Fax:
Practice Address - Street 1:901 S 62ND AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33023-1848
Practice Address - Country:US
Practice Address - Phone:561-790-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6922101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health