Provider Demographics
NPI:1497255210
Name:ETTENBERGER, ANDREA LYN (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYN
Last Name:ETTENBERGER
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:LYN
Other - Last Name:BALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA, RBT
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:1353 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-1433
Practice Address - Country:US
Practice Address - Phone:317-520-4748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-21-49914103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician