Provider Demographics
NPI:1619014891
Name:ETHERIDGE, SAMONIA LYNN (LPC)
Entity Type:Individual
Prefix:MS
First Name:SAMONIA
Middle Name:LYNN
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3218
Mailing Address - Country:US
Mailing Address - Phone:601-636-5703
Mailing Address - Fax:601-636-5739
Practice Address - Street 1:1414 CHERRY ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3218
Practice Address - Country:US
Practice Address - Phone:601-636-5703
Practice Address - Fax:601-636-5739
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1046101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional