Provider Demographics
NPI:1316369374
Name:ETIENNE, CARL (OTR)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:ETIENNE
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 ELMCROFT BLVD APT 3214
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-5642
Mailing Address - Country:US
Mailing Address - Phone:914-319-8014
Mailing Address - Fax:
Practice Address - Street 1:6004 WESTGATE BLVD
Practice Address - Street 2:STE 220
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2503
Practice Address - Country:US
Practice Address - Phone:253-759-4065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06200225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist