Provider Demographics
NPI:1861254666
Name:ETHERIDGE, ALEXANDRA NICOLE
Entity type:Individual
Prefix:MS
First Name:ALEXANDRA
Middle Name:NICOLE
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 1:1318 WAUKEGAN RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-3022
Mailing Address - Country:US
Mailing Address - Phone:847-486-4145
Mailing Address - Fax:
Practice Address - Street 1:1318 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-3022
Practice Address - Country:US
Practice Address - Phone:866-815-4145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-24-321865106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician