Provider Demographics
NPI:1851799605
Name:ETHEREDGE, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:ETHEREDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:DANA
Other - Middle Name:M
Other - Last Name:MCARTHUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1913 PAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-3203
Mailing Address - Country:US
Mailing Address - Phone:512-785-5742
Mailing Address - Fax:
Practice Address - Street 1:4681 COLLEGE PARK
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1526
Practice Address - Country:US
Practice Address - Phone:512-663-0718
Practice Address - Fax:512-706-1956
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2106556225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant