Provider Demographics
NPI:1336652171
Name:ROCKWELL, ETTA JUNE
Entity Type:Individual
Prefix:
First Name:ETTA
Middle Name:JUNE
Last Name:ROCKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2549 YALE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-3337
Mailing Address - Country:US
Mailing Address - Phone:386-506-9319
Mailing Address - Fax:
Practice Address - Street 1:2400 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-3097
Practice Address - Country:US
Practice Address - Phone:386-304-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor