Provider Demographics
NPI:1912213588
Name:ETZEL, DAWN LESLEY
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:LESLEY
Last Name:ETZEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 N WELLS ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-3235
Mailing Address - Country:US
Mailing Address - Phone:260-420-6100
Mailing Address - Fax:574-268-2377
Practice Address - Street 1:1747 N WELLS ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-3235
Practice Address - Country:US
Practice Address - Phone:260-420-6100
Practice Address - Fax:574-268-2377
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86000311A101YA0400X
IN39002304A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)