Provider Demographics
NPI:1790026946
Name:ETHRIDGE, MANDY ELAINE (LPC)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:ELAINE
Last Name:ETHRIDGE
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 1:1661 JAMIE
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513
Mailing Address - Country:US
Mailing Address - Phone:254-535-3688
Mailing Address - Fax:800-747-3074
Practice Address - Street 1:1661 JAMIE
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:TX
Practice Address - Zip Code:76513-9475
Practice Address - Country:US
Practice Address - Phone:254-535-3688
Practice Address - Fax:800-747-3074
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67716101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional