Healthcare Provider Details

I. General information

NPI: 1750950200
Provider Name (Legal Business Name): MENTRAL LEDBETTER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2021
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 2ND ST SW
GORDO AL
35466-2221
US

IV. Provider business mailing address

1607 POWE RD
DEMOPOLIS AL
36732-3431
US

V. Phone/Fax

Practice location:
  • Phone: 334-654-1871
  • Fax: 205-293-5516
Mailing address:
  • Phone: 334-654-1871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC06035
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: