Provider Demographics
NPI:1801123815
Name:ETHRIDGE, BRENDA R (GSL-SP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:R
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:GSL-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 ALBERT GRIMSLEY DR
Mailing Address - Street 2:
Mailing Address - City:COCHRAN
Mailing Address - State:GA
Mailing Address - Zip Code:31014-8321
Mailing Address - Country:US
Mailing Address - Phone:478-934-1728
Mailing Address - Fax:
Practice Address - Street 1:158 ALBERT GRIMSLEY DR
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014-8321
Practice Address - Country:US
Practice Address - Phone:478-934-1728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001141235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000720695BMedicaid