Provider Demographics
NPI:1760954747
Name:ETHERIDGE, ANISHA MONET (RBT)
Entity Type:Individual
Prefix:
First Name:ANISHA
Middle Name:MONET
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 VAUGHN LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-4695
Mailing Address - Country:US
Mailing Address - Phone:251-253-7588
Mailing Address - Fax:
Practice Address - Street 1:2185 NORMANDIE DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2728
Practice Address - Country:US
Practice Address - Phone:205-612-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-01
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst