Healthcare Provider Details

I. General information

NPI: 1215443254
Provider Name (Legal Business Name): MISS LARITHA ANNE ETHRIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 ASHLAND AVE
TOLEDO OH
43620-1703
US

IV. Provider business mailing address

2005 ASHLAND AVE
TOLEDO OH
43620-1703
US

V. Phone/Fax

Practice location:
  • Phone: 419-841-7701
  • Fax:
Mailing address:
  • Phone: 419-841-7701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDA.178652
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: