Provider Demographics
NPI:1518183508
Name:ETHRIDGE, KATIE TAYLOR (MOT, OTRL)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:TAYLOR
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:MOT, OTRL
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 450
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-0450
Mailing Address - Country:US
Mailing Address - Phone:304-760-6300
Mailing Address - Fax:304-201-5123
Practice Address - Street 1:179 STATION PLACE WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-8747
Practice Address - Country:US
Practice Address - Phone:304-760-6300
Practice Address - Fax:304-201-5123
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1310174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCJL75-0029OtherBCBS PROVIDER NUMBER
MD890362-01OtherBCBC PROVIDER NUMBER