Basic Information
| Provider Information | |||||||||
| NPI: | 1326175795 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ETOWAH DEKALB CHEROKEE MENTAL HEALTH BOARD, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CED MENTAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 5TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | ATTALLA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359542214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564927800 | ||||||||
| FaxNumber: | 2564945536 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 5TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | ATTALLA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359542214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564927800 | ||||||||
| FaxNumber: | 2564945536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GROSS VICKERY | ||||||||
| AuthorizedOfficialFirstName: | KASEY | ||||||||
| AuthorizedOfficialMiddleName: | DAWN | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 2564927800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNP | ||||||||
| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 590000012 | 05 | AL | MEDICAID | 330000012 | 05 | AL | MEDICAID | 330034012 | 05 | AL | MEDICAID |