| Doctor Name: | MR. GEORGE GLEN MASSENGILL |
| NPI Number: | 1033447263 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LADAC |
| License Number: | 580 |
| Business Practice Address: | 188 Indian Mound Cir Jacksboro, TN - 377572100 |
| Business Phone Number: | 4235662437 |
| Business Fax Number: | 4235662948 |
| Mailing Address: | 188 Indian Mound Cir, JACKSBORO |
| State: | TN |
| Postal Code: | 377572100 |
| Phone Number: | 4235662437 |
| Fax Number: | 4235662948 |
| NPI Enumeration Date: | 11/30/2009 |
| NPI Last Update Date: | 11/30/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 580 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TN |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |