Provider Demographics
NPI:1407861149
Name:EGLEN, ERNEST III (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:
Last Name:EGLEN
Suffix:III
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1861 IDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-1305
Mailing Address - Country:US
Mailing Address - Phone:404-691-9627
Mailing Address - Fax:404-691-9793
Practice Address - Street 1:475 FAIRBURN RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-1907
Practice Address - Country:US
Practice Address - Phone:404-691-9626
Practice Address - Fax:404-691-9793
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0031361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical