Provider Demographics
NPI:1376924225
Name:ETHERIDGE, MICHAEL A (LMSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:ETHERIDGE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 CHRISTOPHER ST
Mailing Address - Street 2:APT 2BB
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-2803
Mailing Address - Country:US
Mailing Address - Phone:646-408-7382
Mailing Address - Fax:
Practice Address - Street 1:81 WORTH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-3411
Practice Address - Country:US
Practice Address - Phone:646-408-7382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0626371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical