Provider Demographics
NPI:1457603763
Name:ETHRIDGE, MICHELLE
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1492
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-1492
Mailing Address - Country:US
Mailing Address - Phone:713-478-9719
Mailing Address - Fax:
Practice Address - Street 1:14 SANTA CLARITA CIR
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-3352
Practice Address - Country:US
Practice Address - Phone:713-478-9719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator