Provider Demographics
NPI:1316586332
Name:KAMENETZKY, ETTIL (MS ED BCBA)
Entity Type:Individual
Prefix:MRS
First Name:ETTIL
Middle Name:
Last Name:KAMENETZKY
Suffix:
Gender:F
Credentials:MS ED BCBA
Other - Prefix:MRS
Other - First Name:ETTIL
Other - Middle Name:
Other - Last Name:WEISS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS ED BCBA
Mailing Address - Street 1:11 COLORADO DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-2107
Mailing Address - Country:US
Mailing Address - Phone:516-776-7834
Mailing Address - Fax:
Practice Address - Street 1:11 COLORADO DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-2107
Practice Address - Country:US
Practice Address - Phone:516-776-7834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-19-3695103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst