Healthcare Provider Details

I. General information

NPI: 1720089196
Provider Name (Legal Business Name): GRETCHEN DENE ETHEREDGE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 W MAIN ST
LEBANON TN
37087-3302
US

IV. Provider business mailing address

1616 W MAIN ST
LEBANON TN
37087-3100
US

V. Phone/Fax

Practice location:
  • Phone: 615-466-5200
  • Fax: 615-466-5206
Mailing address:
  • Phone: 615-449-0990
  • Fax: 615-449-0970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4695
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: