Provider Demographics
NPI:1548757289
Name:ETKIN, REBECCA GRACE (PHD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:GRACE
Last Name:ETKIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6617
Mailing Address - Country:US
Mailing Address - Phone:917-737-4644
Mailing Address - Fax:
Practice Address - Street 1:350 GEORGE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6617
Practice Address - Country:US
Practice Address - Phone:917-737-4644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-18
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8.004113103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist