Provider Demographics
NPI:1720089196
Name:ETHEREDGE, GRETCHEN DENE (PT)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:DENE
Last Name:ETHEREDGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3100
Mailing Address - Country:US
Mailing Address - Phone:615-449-0990
Mailing Address - Fax:615-449-0970
Practice Address - Street 1:1018 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3302
Practice Address - Country:US
Practice Address - Phone:615-466-5200
Practice Address - Fax:615-466-5206
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3645491Medicaid
TN3645491Medicare ID - Type UnspecifiedMEDICARE, CIGNA, PART BBB