Provider Demographics
NPI:1144207713
Name:ETTLINGER, ETTA F (LCSW)
Entity type:Individual
Prefix:
First Name:ETTA
Middle Name:F
Last Name:ETTLINGER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EXECUTIVE WAY
Mailing Address - Street 2:SUITE #110
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4753
Mailing Address - Country:US
Mailing Address - Phone:904-273-4099
Mailing Address - Fax:904-273-4095
Practice Address - Street 1:100 EXECUTIVE WAY
Practice Address - Street 2:SUITE #110
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-4753
Practice Address - Country:US
Practice Address - Phone:904-273-4099
Practice Address - Fax:904-273-4095
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLCSW63101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ003PAMedicare ID - Type UnspecifiedMEDICARE PROVIDER NO.