Provider Demographics
NPI:1205238268
Name:MCBRIDE, CLEA
Entity type:Individual
Prefix:
First Name:CLEA
Middle Name:
Last Name:MCBRIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CLEA
Other - Middle Name:MCBRIDE
Other - Last Name:ETHERIDGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:118 NORTH AVE
Mailing Address - Street 2:STE-K
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-8405
Mailing Address - Country:US
Mailing Address - Phone:678-348-6824
Mailing Address - Fax:
Practice Address - Street 1:118 NORTH AVE
Practice Address - Street 2:STE-K
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-8405
Practice Address - Country:US
Practice Address - Phone:678-348-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT006647173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist