Provider Demographics
NPI:1376329698
Name:ELDRIDGE, DEVYNNE TAYLOR-FAYE
Entity Type:Individual
Prefix:
First Name:DEVYNNE
Middle Name:TAYLOR-FAYE
Last Name:ELDRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 SIMPSON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-9498
Mailing Address - Country:US
Mailing Address - Phone:740-395-1383
Mailing Address - Fax:
Practice Address - Street 1:306 W UNION ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2312
Practice Address - Country:US
Practice Address - Phone:740-764-4529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-01
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHC.2405559-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator