Provider Demographics
NPI:1619669777
Name:ETTORI, BRIANNA I (MA, CAGS)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:ETTORI
Suffix:I
Gender:F
Credentials:MA, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 VILLA ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94041-1236
Mailing Address - Country:US
Mailing Address - Phone:888-688-9296
Mailing Address - Fax:
Practice Address - Street 1:432 BUTLER ROAD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:12837
Practice Address - Country:US
Practice Address - Phone:518-409-2434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT8066375103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool