Provider Demographics
NPI:1609885391
Name:ETTER, LARRY D (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:ETTER
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10010 SAN PEDRO AVE
Mailing Address - Street 2:# 610
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-3862
Mailing Address - Country:US
Mailing Address - Phone:210-414-3259
Mailing Address - Fax:210-222-8030
Practice Address - Street 1:10010 SAN PEDRO AVE
Practice Address - Street 2:# 610
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-3862
Practice Address - Country:US
Practice Address - Phone:210-414-3259
Practice Address - Fax:210-222-8030
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12043101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148510402Medicaid
TX148510401Medicaid
TX1485104-05Medicaid