Provider Demographics
NPI:1992541445
Name:ETHRIDGE, ALEXIS ARIELLE (MA, RMHCI)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ARIELLE
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:MA, RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3606 GRUNTHAL ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-3807
Mailing Address - Country:US
Mailing Address - Phone:904-537-4621
Mailing Address - Fax:
Practice Address - Street 1:1530 CORNERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7128
Practice Address - Country:US
Practice Address - Phone:904-855-9169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH26000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health