Provider Demographics
NPI:1962705863
Name:ETHERIDGE, MARTIN SEAN
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:SEAN
Last Name:ETHERIDGE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 W MCGREGOR ST
Mailing Address - Street 2:
Mailing Address - City:PAGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29728-2137
Mailing Address - Country:US
Mailing Address - Phone:843-672-7096
Mailing Address - Fax:
Practice Address - Street 1:212 W MCGREGOR ST
Practice Address - Street 2:
Practice Address - City:PAGELAND
Practice Address - State:SC
Practice Address - Zip Code:29728-2137
Practice Address - Country:US
Practice Address - Phone:843-672-7096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-15
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6059101YP2500X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional