NPIMap

Organization Active NPI

Etheridge Psychology, P.a.

  • Psychologist
  • Cary, NC
National Provider Identifier
1275820144
Registry record updated Jan 24, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
PsychologistTaxonomy code 103T00000X
License
3686 Issued in NC
Legal business name
ETHERIDGE PSYCHOLOGY, P.A.
Practice address
115 Kildaire Park Dr Ste 313
Cary, NC 27518-8144
Phone
(919) 600-4906
Fax
(888) 887-6361
NPI assigned
Jun 29, 2011
Last updated
Jan 24, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 24, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Mary Anne Etheridge, PHDNPI 1437294212
Title
President
Phone
(919) 600-4906

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103T00000X 3686 NC Primary
PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103T00000X

Addresses

Primary practice location

115 Kildaire Park Dr Ste 313
Cary, NC 27518-8144

Mailing address

115 Kildaire Park Dr Ste 313
Cary, NC 27518-8144
Phone (919) 600-4906

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120803000032 NC Part B Supplier - Clinic/Group Practice 0446406649 Receives reassigned benefits from 3 practitioners
Practice locations: Cary, NC

National Provider Directory

National Provider Directory

Locations

115 Kildaire Park Dr
Ste 313
Cary, NC 27518
Phone (919) 600-4906

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1309305600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1579824000000",
    "number": "1275820144",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "115 KILDAIRE PARK DR STE 313",
            "city": "CARY",
            "state": "NC",
            "postal_code": "275188144",
            "telephone_number": "919-600-4906",
            "fax_number": "888-887-6361"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "115 KILDAIRE PARK DR STE 313",
            "city": "CARY",
            "state": "NC",
            "postal_code": "275188144",
            "telephone_number": "919-600-4906",
            "fax_number": "888-887-6361"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ETHERIDGE PSYCHOLOGY, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-06-29",
        "last_updated": "2020-01-24",
        "certification_date": "2020-01-24",
        "status": "A",
        "authorized_official_last_name": "ETHERIDGE",
        "authorized_official_first_name": "MARY",
        "authorized_official_middle_name": "ANNE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "919-600-4906",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": "NC",
            "license": "3686",
            "primary": true
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Cary, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 24, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.