Healthcare Provider Details

I. General information

NPI: 1891444311
Provider Name (Legal Business Name): MELISSA RUTH ETHRIDGE LPC-MHSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 RIDGEWAY LOOP RD STE 200
MEMPHIS TN
38120-4026
US

IV. Provider business mailing address

1211 UNION AVE STE 330
MEMPHIS TN
38104-6655
US

V. Phone/Fax

Practice location:
  • Phone: 901-821-9990
  • Fax: 901-821-9991
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC0000004833
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: