Provider Demographics
NPI:1649934407
Name:ETHEREDGE, JOSEPH HUGH (LPC)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:HUGH
Last Name:ETHEREDGE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 GRIZZLY TRL
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4974
Mailing Address - Country:US
Mailing Address - Phone:470-729-0987
Mailing Address - Fax:
Practice Address - Street 1:263 ALMON RD
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-1903
Practice Address - Country:US
Practice Address - Phone:770-546-5398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC014279101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional