Provider Demographics
NPI:1033500178
Name:VAN ETTEN, TODD
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:VAN ETTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26318 MISTY GLN
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-7249
Mailing Address - Country:US
Mailing Address - Phone:949-202-8905
Mailing Address - Fax:
Practice Address - Street 1:26318 MISTY GLN
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-7249
Practice Address - Country:US
Practice Address - Phone:949-202-8905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9605225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant