Provider Demographics
NPI:1669225553
Name:ETHRIDGE, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:ETHRIDGE
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 1:5001 W FLORIDA AVE SPC 688
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-3822
Mailing Address - Country:US
Mailing Address - Phone:951-531-6785
Mailing Address - Fax:
Practice Address - Street 1:24230 BARTON RD
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3232
Practice Address - Country:US
Practice Address - Phone:813-720-9825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty