Provider Demographics
NPI:1003374752
Name:ETHERIDGE, NICHOLAS A (LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:ETHERIDGE
Suffix:
Gender:M
Credentials:LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 HARFORD RD STE 201
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-2290
Mailing Address - Country:US
Mailing Address - Phone:667-706-9091
Mailing Address - Fax:
Practice Address - Street 1:5500 HARFORD RD STE 201
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-2290
Practice Address - Country:US
Practice Address - Phone:667-706-9091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC11427101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional