MEDICARE: MRS. KRISTYN ROUSE ETHEREDGE LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	3323	AL
2	101YM0800X	Mental Health Counselor	C2041A	AL

General Provider Information

NPI Number	:	1962755660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTYN ROUSE ETHEREDGE LPC

Provider Business Mailing Address
First Line	:	100 WESTSIDE DR
Second Line	:
City	:	DOTHAN
State	:	AL
Zip	:	36303-1908
Country	:	US
Telephone Number	:	334-793-2237
Fax Number	:	334-712-6256

Provider Business Practice Location Address
First Line	:	100 WESTSIDE DR.
Second Line	:
City	:	DOTHAN
State	:	AL
Zip	:	36303
Country	:	US
Telephone Number	:	334-793-2237
Fax Number	:	334-712-6256

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2012
Last Update Date	:	12/11/2025

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