Provider Demographics
NPI:1689192510
Name:SMILEDGE, GEORGE (LPC)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:SMILEDGE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 ANLO AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-4952
Mailing Address - Country:US
Mailing Address - Phone:254-498-0730
Mailing Address - Fax:208-216-7762
Practice Address - Street 1:1838 N VALLEY MILLS DR STE 6
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2557
Practice Address - Country:US
Practice Address - Phone:254-498-0730
Practice Address - Fax:208-216-7622
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2024-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-10510101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health