Provider Demographics
NPI:1861594483
Name:ETHERIDGE, RICKEY (LPC)
Entity type:Individual
Prefix:
First Name:RICKEY
Middle Name:
Last Name:ETHERIDGE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3348 MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-5013
Mailing Address - Country:US
Mailing Address - Phone:501-443-3824
Mailing Address - Fax:501-521-1001
Practice Address - Street 1:3348 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-5013
Practice Address - Country:US
Practice Address - Phone:501-443-3824
Practice Address - Fax:501-521-1001
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0907039101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116378726Medicaid