Provider Demographics
NPI:1497476873
Name:ETIENNE, OETTLY
Entity Type:Individual
Prefix:
First Name:OETTLY
Middle Name:
Last Name:ETIENNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OETTLY
Other - Middle Name:
Other - Last Name:ETIENNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LEE
Mailing Address - Street 1:8245 VICELA DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34240-1462
Mailing Address - Country:US
Mailing Address - Phone:800-210-0814
Mailing Address - Fax:
Practice Address - Street 1:8245 VICELA DR
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34240-1462
Practice Address - Country:US
Practice Address - Phone:239-778-7490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician