Provider Demographics
NPI:1538503362
Name:ETZEL, TYANN (BS, CADC I)
Entity Type:Individual
Prefix:MRS
First Name:TYANN
Middle Name:
Last Name:ETZEL
Suffix:
Gender:F
Credentials:BS, CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2586 12TH PL SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2536
Mailing Address - Country:US
Mailing Address - Phone:503-371-4160
Mailing Address - Fax:
Practice Address - Street 1:2586 12TH PL SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2536
Practice Address - Country:US
Practice Address - Phone:503-371-4160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13-03-17101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)