Healthcare Provider Details

I. General information

NPI: 1164668869
Provider Name (Legal Business Name): ETHEREDGE AND SHELTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2008
Last Update Date: 12/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 E HIRAM ST
ATLANTA TX
75551-2661
US

IV. Provider business mailing address

1204 HOLLY ST
ATLANTA TX
75551-1842
US

V. Phone/Fax

Practice location:
  • Phone: 903-796-5061
  • Fax:
Mailing address:
  • Phone: 903-796-5061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number02075
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00276
License Number StateTX

VIII. Authorized Official

Name: GAY HILL ETHEREDGE
Title or Position: PRESIDENT
Credential: LCSW
Phone: 903-277-7732