Healthcare Provider Details

I. General information

NPI: 1407861149
Provider Name (Legal Business Name): ERNEST EGLEN III LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 FAIRBURN RD SW
ATLANTA GA
30331-1907
US

IV. Provider business mailing address

1861 IDLEWOOD DR
EAST POINT GA
30344-1305
US

V. Phone/Fax

Practice location:
  • Phone: 404-691-9626
  • Fax: 404-691-9793
Mailing address:
  • Phone: 404-691-9627
  • Fax: 404-691-9793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003136
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: