Healthcare Provider Details

I. General information

NPI: 1447869763
Provider Name (Legal Business Name): GLACIA ETHRIDGE DAVIS LCMHC, LPC, CRC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6650 RIVERS AVE STE 100
NORTH CHARLESTON SC
29406-4809
US

IV. Provider business mailing address

224 FOX RUN DR
HOPKINS SC
29061-8662
US

V. Phone/Fax

Practice location:
  • Phone: 803-606-9932
  • Fax:
Mailing address:
  • Phone: 803-606-9932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24415
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10865
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15500
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: