Provider Demographics
NPI:1215232434
Name:ETHERIDGE, ROY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:L
Last Name:ETHERIDGE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 SE CARY PKWY STE 201
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7413
Mailing Address - Country:US
Mailing Address - Phone:919-600-4906
Mailing Address - Fax:888-887-6361
Practice Address - Street 1:115 KILDAIRE PARK DR STE 313
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8144
Practice Address - Country:US
Practice Address - Phone:919-600-4906
Practice Address - Fax:888-887-6361
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3895103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist