Provider Demographics
NPI:1093868408
Name:ETZRODT, LAURIE E (MSS,LCSW)
Entity Type:Individual
Prefix:MISS
First Name:LAURIE
Middle Name:E
Last Name:ETZRODT
Suffix:
Gender:F
Credentials:MSS,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 OXFORD VALLEY RD STE 304A
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-7709
Mailing Address - Country:US
Mailing Address - Phone:215-493-8896
Mailing Address - Fax:215-340-1867
Practice Address - Street 1:301 OXFORD VALLEY RD STE 304A
Practice Address - Street 2:
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-7709
Practice Address - Country:US
Practice Address - Phone:215-493-8896
Practice Address - Fax:215-340-1867
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0144881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAET658579Medicare ID - Type UnspecifiedCLINICAL SOCIAL WORKER