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General NPI Number Information
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NPI Number | 1205466885
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Entity Type | Individual
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Provider Name | WILLIAM THOMAS GORDON ETHERIDGE
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Gender | Male
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Dates
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Enumeration Date | 01/22/2020
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Last Update Date | 09/15/2023
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Provider Practice Location Address
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Address Line | THRIVEWORKS 8406 SIX FORKS RD SUITE 104
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City | RALEIGH
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State | NC
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Zip | 27615
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Country | US
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Telephone | 919-642-4857
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Fax |
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Provider Business Mailing Address
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Address Line | 122 MASONDALE AVE
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City | DURHAM
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State | NC
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Zip | 27707-3152
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Country | US
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Telephone | 919-308-7306
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 15542
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License Number State | NC
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