Provider Demographics
NPI:1366738072
Name:REHKAMP, GEORGE J (AS)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:J
Last Name:REHKAMP
Suffix:
Gender:M
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-2310
Mailing Address - Country:US
Mailing Address - Phone:203-574-9000
Mailing Address - Fax:203-574-9006
Practice Address - Street 1:141 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702
Practice Address - Country:US
Practice Address - Phone:203-574-9000
Practice Address - Fax:203-574-9006
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1221101YA0400X
CT3366101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCAC-5287OtherCONNECTICUT CERTIFICATION BOARD, INC
CTCIT-5287OtherCONNECTICUT CERTIFICATION BOARD, INC.
CTICADC-5287OtherCONNECTICUT CERTIFICATION BOARD