Provider Demographics
NPI:1164668869
Name:ETHEREDGE AND SHELTON, LLC
Entity Type:Organization
Organization Name:ETHEREDGE AND SHELTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GAY
Authorized Official - Middle Name:HILL
Authorized Official - Last Name:ETHEREDGE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:903-277-7732
Mailing Address - Street 1:1204 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:TX
Mailing Address - Zip Code:75551-1842
Mailing Address - Country:US
Mailing Address - Phone:903-796-5061
Mailing Address - Fax:
Practice Address - Street 1:207 E HIRAM ST
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551-2661
Practice Address - Country:US
Practice Address - Phone:903-796-5061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX002761041C0700X
TX020751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty