Provider Demographics
NPI:1538708292
Name:ETHERIDGE, ASHLEY VICTORIA
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:VICTORIA
Last Name:ETHERIDGE
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 1:5143 BECKFORD DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-4907
Mailing Address - Country:US
Mailing Address - Phone:704-604-9630
Mailing Address - Fax:
Practice Address - Street 1:5950 FAIRVIEW RD STE 770
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3142
Practice Address - Country:US
Practice Address - Phone:704-457-7834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-29
Last Update Date:2019-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14870101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health