Provider Demographics
NPI:1427542331
Name:ETIENNE, PHARA (BA)
Entity Type:Individual
Prefix:MISS
First Name:PHARA
Middle Name:
Last Name:ETIENNE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MRS
Other - First Name:VALERIE
Other - Middle Name:N/A
Other - Last Name:MANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:1730 S FEDERAL HWY # 268
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33483-3309
Mailing Address - Country:US
Mailing Address - Phone:305-305-6367
Mailing Address - Fax:
Practice Address - Street 1:1730 S FEDERAL HWY # 268
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33483-3309
Practice Address - Country:US
Practice Address - Phone:305-305-6367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL205268843106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician