Healthcare Provider Details

I. General information

NPI: 1225068794
Provider Name (Legal Business Name): GEORGE THOMAS NETHERTON LPC LPE LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 YVONNE AVENUE
CROSSVILLE TN
38555-1569
US

IV. Provider business mailing address

87 DADDYS CREEK LANE
CROSSVILLE TN
38555-1569
US

V. Phone/Fax

Practice location:
  • Phone: 931-707-8921
  • Fax: 931-707-8921
Mailing address:
  • Phone: 931-707-8921
  • Fax: 931-707-8921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC00735
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPE011566
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: