Provider Demographics
NPI:1619307618
Name:ELLEDGE, ABIGAIL
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:ELLEDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 BRETT RD
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76210-1613
Mailing Address - Country:US
Mailing Address - Phone:940-293-5705
Mailing Address - Fax:
Practice Address - Street 1:3003 BRETT RD
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:TX
Practice Address - Zip Code:76210-1613
Practice Address - Country:US
Practice Address - Phone:940-293-5705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX518071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical