Provider Demographics
NPI:1326560889
Name:ETZBACH, COLLEEN (RHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:
Last Name:ETZBACH
Suffix:
Gender:F
Credentials:RHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 BROADWAY ST N STE 114B
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-4728
Mailing Address - Country:US
Mailing Address - Phone:715-308-5742
Mailing Address - Fax:888-972-4831
Practice Address - Street 1:1421 BROADWAY ST N STE 114B
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-4728
Practice Address - Country:US
Practice Address - Phone:715-308-5742
Practice Address - Fax:888-972-4831
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5537101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional