Provider Demographics
NPI:1568743342
Name:ETHRIDGE, NECIA M (LMHC)
Entity Type:Individual
Prefix:MS
First Name:NECIA
Middle Name:M
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 LA LUZ DRIVE
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6489
Mailing Address - Country:US
Mailing Address - Phone:575-770-2137
Mailing Address - Fax:
Practice Address - Street 1:1337 GUSDORF ROAD
Practice Address - Street 2:SUITE E
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-758-4297
Practice Address - Fax:575-751-7237
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2013-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0159201101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health