Provider Demographics
NPI:1023508579
Name:ELDRIDGE, ICA DRAUGHN (NC LMBT# 12464)
Entity type:Individual
Prefix:MRS
First Name:ICA
Middle Name:DRAUGHN
Last Name:ELDRIDGE
Suffix:
Gender:F
Credentials:NC LMBT# 12464
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:492 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-3814
Mailing Address - Country:US
Mailing Address - Phone:336-783-0055
Mailing Address - Fax:336-648-8084
Practice Address - Street 1:492 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-3814
Practice Address - Country:US
Practice Address - Phone:336-783-0055
Practice Address - Fax:336-648-8084
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12464225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist