Provider Demographics
NPI:1083180194
Name:PIEDMONT THERAPEUTICS, PLLC
Entity Type:Organization
Organization Name:PIEDMONT THERAPEUTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MAJORS
Authorized Official - Last Name:ETHRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:980-689-0778
Mailing Address - Street 1:321 EAST BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4815
Mailing Address - Country:US
Mailing Address - Phone:980-689-0778
Mailing Address - Fax:
Practice Address - Street 1:321 EAST BLVD APT 3
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4815
Practice Address - Country:US
Practice Address - Phone:980-689-0778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-16
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1538597331Medicaid
NC1871921494Medicaid