Provider Demographics
NPI:1336395920
Name:ETTS, MICHAEL (LCSW-C, ACH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ETTS
Suffix:
Gender:M
Credentials:LCSW-C, ACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 LA GRANGE AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-9592
Mailing Address - Country:US
Mailing Address - Phone:240-253-7051
Mailing Address - Fax:301-934-2640
Practice Address - Street 1:109 LA GRANGE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-9592
Practice Address - Country:US
Practice Address - Phone:240-253-7051
Practice Address - Fax:301-934-2640
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-14
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15506104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker