Provider Demographics
NPI:1821382763
Name:ETTINGER, JOAN E (CASAC)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:E
Last Name:ETTINGER
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 S HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1178
Mailing Address - Country:US
Mailing Address - Phone:631-261-0517
Mailing Address - Fax:
Practice Address - Street 1:64 S HARBOR RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-1178
Practice Address - Country:US
Practice Address - Phone:631-261-0517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3855101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)