Provider Demographics
NPI:1922471440
Name:ETHERIDGE, CORA ANN (LMHC)
Entity Type:Individual
Prefix:MS
First Name:CORA
Middle Name:ANN
Last Name:ETHERIDGE
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 1:1213 WINDING MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:ROCKRIDGE FL
Mailing Address - State:FL
Mailing Address - Zip Code:32955-8404
Mailing Address - Country:US
Mailing Address - Phone:321-784-5367
Mailing Address - Fax:
Practice Address - Street 1:3040 NO. WICKHAM RD, SUITE 3
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2699
Practice Address - Country:US
Practice Address - Phone:321-223-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13764101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health