Provider Demographics
NPI:1326175795
Name:ETOWAH DEKALB CHEROKEE MENTAL HEALTH BOARD, INC
Entity Type:Organization
Organization Name:ETOWAH DEKALB CHEROKEE MENTAL HEALTH BOARD, INC
Other - Org Name:CED MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KASEY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:GROSS VICKERY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:256-492-7800
Mailing Address - Street 1:425 5TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ATTALLA
Mailing Address - State:AL
Mailing Address - Zip Code:35954-2214
Mailing Address - Country:US
Mailing Address - Phone:256-492-7800
Mailing Address - Fax:256-494-5536
Practice Address - Street 1:425 5TH AVE NW
Practice Address - Street 2:
Practice Address - City:ATTALLA
Practice Address - State:AL
Practice Address - Zip Code:35954-2214
Practice Address - Country:US
Practice Address - Phone:256-492-7800
Practice Address - Fax:256-494-5536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL590000012Medicaid
AL330000012Medicaid
AL330034012Medicaid