Provider Demographics
NPI:1801338538
Name:ETHERIDGE, SHANTALE
Entity type:Individual
Prefix:
First Name:SHANTALE
Middle Name:
Last Name:ETHERIDGE
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 1:2403 W STAN SCHLUETER LOOP UNIT 690125
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-0206
Mailing Address - Country:US
Mailing Address - Phone:254-499-2905
Mailing Address - Fax:
Practice Address - Street 1:2403 W STAN SCHLUETER LOOP UNIT 690125
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-0206
Practice Address - Country:US
Practice Address - Phone:254-499-2905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-11
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1920101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional