Provider Demographics
NPI:1558433888
Name:ETHRIDGE, GAYE BROWN (MSW)
Entity Type:Individual
Prefix:
First Name:GAYE
Middle Name:BROWN
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LAKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-5419
Mailing Address - Country:US
Mailing Address - Phone:478-477-7982
Mailing Address - Fax:478-464-1356
Practice Address - Street 1:144 PIERCE AVE
Practice Address - Street 2:CROSSROADS COUNSELING CENTER
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2860
Practice Address - Country:US
Practice Address - Phone:478-475-4608
Practice Address - Fax:478-476-8397
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0006091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical