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General NPI Number Information
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NPI Number | 1780220145
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Entity Type | Individual
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Provider Name | JAMES MICHAEL ETHRIDGE LMSW
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Gender | Male
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Dates
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Enumeration Date | 11/20/2019
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Last Update Date | 11/20/2019
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Provider Practice Location Address
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Address Line | 3710 SW US VETERANS HOSPITAL RD
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City | PORTLAND
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State | OR
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Zip | 97239-2964
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Country | US
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Telephone | 503-220-8262
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 505
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City | SEASIDE
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State | OR
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Zip | 97138-0505
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Country | US
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Telephone | 503-841-7722
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | M6016
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License Number State | OR
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