Provider Demographics
NPI:1932293693
Name:ETZEL, JULIE C (PHD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:C
Last Name:ETZEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1169 EASTERN PKWY
Mailing Address - Street 2:SUITE 2266
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1417
Mailing Address - Country:US
Mailing Address - Phone:502-238-3178
Mailing Address - Fax:502-238-3653
Practice Address - Street 1:1169 EASTERN PKWY
Practice Address - Street 2:SUITE 3357
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1417
Practice Address - Country:US
Practice Address - Phone:502-454-0755
Practice Address - Fax:502-479-1231
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1616103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1616OtherKY PSYCHOLOGY LICENSE
IL071-007127OtherIL STATE LIC
IL071-007127OtherIL STATE LIC