Basic Information
| Provider Information | |||||||||
| NPI: | 1295770535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORTER | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | WILEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | PH. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2217 DELLWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322043101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | VAMC - UNIT 9 - 116B | ||||||||
| Address2: | 619 S. MARION AVE | ||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 1244 | AL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.