Healthcare Provider Details

I. General information

NPI: 1245856566
Provider Name (Legal Business Name): MEREDITH K GINLEY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 DEROSIER DR
JOHNSON CITY TN
37614-5200
US

IV. Provider business mailing address

PO BOX 70416 ETSU DEPARTMENT OF PSYCHOLOGY
JOHNSON CITY TN
37614
US

V. Phone/Fax

Practice location:
  • Phone: 423-439-7777
  • Fax: 423-439-7780
Mailing address:
  • Phone: 423-439-4113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3598
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: