Healthcare Provider Details

I. General information

NPI: 1669225553
Provider Name (Legal Business Name): TERESA ETHRIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 12/28/2024
Certification Date: 12/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24230 BARTON RD
LOMA LINDA CA
92354-3232
US

IV. Provider business mailing address

5001 W FLORIDA AVE SPC 688
HEMET CA
92545-3822
US

V. Phone/Fax

Practice location:
  • Phone: 813-720-9825
  • Fax:
Mailing address:
  • Phone: 951-531-6785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: