Provider Demographics
NPI:1881047355
Name:ETHERINGTON, LAURIE JEAN (PT)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:JEAN
Last Name:ETHERINGTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 BRIDGE BARRIER RD
Mailing Address - Street 2:BLDG 3
Mailing Address - City:CAROLINA BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28428-3938
Mailing Address - Country:US
Mailing Address - Phone:910-458-8884
Mailing Address - Fax:910-458-3976
Practice Address - Street 1:1300 BRIDGE BARRIER RD
Practice Address - Street 2:BLDG 3
Practice Address - City:CAROLINA BEACH
Practice Address - State:NC
Practice Address - Zip Code:28428-3938
Practice Address - Country:US
Practice Address - Phone:910-458-8884
Practice Address - Fax:910-458-3976
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP9722225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist