Provider Demographics
NPI:1184770711
Name:ETHRIDGE, BRIAN LEE (PTA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEE
Last Name:ETHRIDGE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7704 WESTCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3600
Mailing Address - Country:US
Mailing Address - Phone:608-445-3317
Mailing Address - Fax:
Practice Address - Street 1:333 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2777
Practice Address - Country:US
Practice Address - Phone:608-283-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI794-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant