Provider Demographics
NPI:1689732455
Name:ETZEL, LISABETH (MA)
Entity Type:Individual
Prefix:
First Name:LISABETH
Middle Name:
Last Name:ETZEL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 WALKER AVENUE
Mailing Address - Street 2:
Mailing Address - City:KITTERY
Mailing Address - State:ME
Mailing Address - Zip Code:03904
Mailing Address - Country:US
Mailing Address - Phone:207-752-7230
Mailing Address - Fax:
Practice Address - Street 1:31 WALKER AVE
Practice Address - Street 2:
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904-1525
Practice Address - Country:US
Practice Address - Phone:207-752-7230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0082841101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
201079803OtherPRESBY
NMG9368Medicaid
NMG9368Medicaid