Provider Demographics
NPI:1003111717
Name:ETHERIDGE, JOANNE CAROL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JOANNE
Middle Name:CAROL
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31625 HIGHWAY 101 S
Mailing Address - Street 2:
Mailing Address - City:SOLEDAD
Mailing Address - State:CA
Mailing Address - Zip Code:93960-9529
Mailing Address - Country:US
Mailing Address - Phone:831-678-5500
Mailing Address - Fax:
Practice Address - Street 1:31625 HIGHWAY 101 S
Practice Address - Street 2:
Practice Address - City:SOLEDAD
Practice Address - State:CA
Practice Address - Zip Code:93960-9529
Practice Address - Country:US
Practice Address - Phone:831-678-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 88551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZCPR702A51404OtherANTHEM BLUE CROSS