Basic Information
| Provider Information | |||||||||
| NPI: | 1336660224 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETHERIDGE | ||||||||
| FirstName: | DANITRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 BANKS AVE | ||||||||
| Address2: | |||||||||
| City: | MCADOO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 182372508 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9250 GAITHER RD | ||||||||
| Address2: | |||||||||
| City: | GAITHERSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208771420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708023099 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2017 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 906931804 | 01 | MD | UNITED HEALTH CARE | OTHER |