MEDICARE: NICOLE DARLENE ETHRIDGE MA, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	37PC00899200	NJ
2	101Y00000X	Counselor	2018013675	MO
3	101YP2500X	Professional Counselor	PC-0011186	DE
4	101YP2500X	Professional Counselor	16030	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760974596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE DARLENE ETHRIDGE MA, LPC

Provider Business Mailing Address
First Line	:	1300 E BRADFORD PKWY
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-4264
Country	:	US
Telephone Number	:	417-761-5000
Fax Number	:	417-761-5065

Provider Business Practice Location Address
First Line	:	5904 WARNER AVE UNIT 413
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-4670
Country	:	US
Telephone Number	:	909-898-7886
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2018
Last Update Date	:	01/05/2026

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