MEDICARE: MRS. SONIA REYES ETHRIDGE LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	60665	TX

General Provider Information

NPI Number	:	1215129796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SONIA REYES ETHRIDGE LPC

Provider Business Mailing Address
First Line	:	2001 CHICON ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78722-2428
Country	:	US
Telephone Number	:	512-735-2106
Fax Number	:	512-735-2183

Provider Business Practice Location Address
First Line	:	2001 CHICON ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78722-2428
Country	:	US
Telephone Number	:	512-735-2106
Fax Number	:	512-735-2183

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2007
Last Update Date	:	08/17/2007

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