Provider Demographics
NPI:1053821884
Name:ETTER, MAURICE SHANE (LCSW, CSAC)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:SHANE
Last Name:ETTER
Suffix:
Gender:M
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2328 PETERS CREEK RD NW STE 102
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-1621
Mailing Address - Country:US
Mailing Address - Phone:540-345-2606
Mailing Address - Fax:540-345-2608
Practice Address - Street 1:504 23RD ST NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-5414
Practice Address - Country:US
Practice Address - Phone:540-345-2606
Practice Address - Fax:540-345-2608
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
VA10538218841041C0700X
VA09040099511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)