Provider Demographics
NPI:1548534514
Name:ETSITTY, ROSE M
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:ETSITTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:M
Other - Last Name:ETSITTY-GLASSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX PH
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-8000
Mailing Address - Country:US
Mailing Address - Phone:928-674-7166
Mailing Address - Fax:928-674-7705
Practice Address - Street 1:HIGHWAY 191 AND HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-7166
Practice Address - Fax:928-674-7705
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
139974OtherAMERICAN SCHOOL COUNSELORS ASSOCIATION