Provider Demographics
NPI:1063533842
Name:HEARNE, GEORGE WALLACE (LCSW)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:WALLACE
Last Name:HEARNE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3517 MARCONI AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-5328
Mailing Address - Country:US
Mailing Address - Phone:916-482-3070
Mailing Address - Fax:916-482-3070
Practice Address - Street 1:3517 MARCONI AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-5328
Practice Address - Country:US
Practice Address - Phone:916-482-3070
Practice Address - Fax:916-482-3070
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 133331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA112764 UBSOtherUNITED BEHAVIORAL HEALTH
CA7479110OtherAETNA BEHAVIORAL HEALTH
CA049741OtherMHN
CA049741OtherMHN