Provider Demographics
NPI:1447863063
Name:ETHRIDGE-HICKS, MARIBETH DIPPIE
Entity type:Individual
Prefix:MS
First Name:MARIBETH
Middle Name:DIPPIE
Last Name:ETHRIDGE-HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985 BETHLEHEM CHURCH LN
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995-3717
Mailing Address - Country:US
Mailing Address - Phone:618-771-3698
Mailing Address - Fax:
Practice Address - Street 1:206 W 5TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-1810
Practice Address - Country:US
Practice Address - Phone:618-524-9368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)