MEDICARE: NICOLE ETHRIDGE M.S., CCC-SLP

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	235Z00000X	Speech-Language Pathologist	SLP013955	GA
2	235Z00000X	Speech-Language Pathologist	120148	TX

General Provider Information

NPI Number	:	1891545950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE ETHRIDGE M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	110 PIPEMAKERS CIR STE 115
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-4168
Country	:	US
Telephone Number	:	912-988-1526
Fax Number	:	912-988-1537

Provider Business Practice Location Address
First Line	:	110 PIPEMAKERS CIR STE 115
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-4168
Country	:	US
Telephone Number	:	912-988-1526
Fax Number	:	912-988-1537

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

Provider Enumeration Date	:	03/22/2024
Last Update Date	:	02/03/2026

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Directions to “ NICOLE ETHRIDGE M.S., CCC-SLP” Practice Location

Language	Start Address	Practice Location

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