Provider Demographics
NPI:1447869763
Name:ETHRIDGE, GLACIA (LCMHCA, LCAS-A, CRC)
Entity type:Individual
Prefix:DR
First Name:GLACIA
Middle Name:
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:LCMHCA, LCAS-A, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14309 DELANEY DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8287
Mailing Address - Country:US
Mailing Address - Phone:704-517-7292
Mailing Address - Fax:
Practice Address - Street 1:1923 J N PEASE PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4513
Practice Address - Country:US
Practice Address - Phone:980-213-0796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15500101YM0800X
NC24415101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty