MEDICARE: ETHEL'S PLACE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor		GA

General Provider Information

NPI Number	:	1225253354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETHEL'S PLACE, INC.

Provider Business Mailing Address
First Line	:	302 W I PKWY
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30132-5061
Country	:	US
Telephone Number	:	678-363-3799
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 W I PKWY
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30132-5061
Country	:	US
Telephone Number	:	678-363-3799
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. GEORGE WILLIAMS
Credential	:
Telephone Number	:	678-858-6283

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	08/22/2020

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Directions to “ETHEL'S PLACE, INC. ” Practice Location

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