Provider Demographics
NPI:1366564999
Name:ETHERIDGE, TERRILYN (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:TERRILYN
Middle Name:
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:MRS
Other - First Name:TERRILYN
Other - Middle Name:
Other - Last Name:ETHERIDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:1420 TROUVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-2944
Mailing Address - Country:US
Mailing Address - Phone:757-478-6006
Mailing Address - Fax:
Practice Address - Street 1:5900 CHURCHLAND BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3313
Practice Address - Country:US
Practice Address - Phone:757-483-0333
Practice Address - Fax:757-483-9359
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA191880OtherANTHEM BLUE CROSS
VA371787OtherMDIPA
VA62413OtherMAILHANDLERS
VA808578OtherMPN
VA26207OtherOPTIMA MEDICARE
VA808578OtherMPN