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General NPI Number Information
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NPI Number | 1164668869
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Entity Type | Organization
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Legal Business Name | ETHEREDGE AND SHELTON, LLC
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Dates
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Enumeration Date | 12/30/2008
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Last Update Date | 12/30/2008
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Provider Practice Location Address
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Address Line | 207 E HIRAM ST
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City | ATLANTA
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State | TX
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Zip | 75551-2661
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Country | US
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Telephone | 903-796-5061
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Fax |
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Provider Business Mailing Address
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Address Line | 1204 HOLLY ST
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City | ATLANTA
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State | TX
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Zip | 75551-1842
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Country | US
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Telephone | 903-796-5061
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | GAY HILL ETHEREDGE
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Credential | LCSW
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Telephone | 903-277-7732
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 02075
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 00276
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License Number State | TX
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