Provider Demographics
NPI:1457819443
Name:ETHERIDGE, MOLLY A (MS CCC-SLP/L)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:A
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 W INDIAN TRL APT 5
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-6028
Mailing Address - Country:US
Mailing Address - Phone:309-846-1613
Mailing Address - Fax:
Practice Address - Street 1:1201 W NEW YORK ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3667
Practice Address - Country:US
Practice Address - Phone:309-846-1613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.013754235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist