Provider Demographics
NPI:1912099862
Name:ETZKORN, WENDY G (MSW LICSW)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:G
Last Name:ETZKORN
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 STONEGATE DRIVE
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526
Mailing Address - Country:US
Mailing Address - Phone:304-545-8629
Mailing Address - Fax:
Practice Address - Street 1:104 STATION PLACE WAY
Practice Address - Street 2:APPALACHIAN FAMILY MEDICINE
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526
Practice Address - Country:US
Practice Address - Phone:304-757-7788
Practice Address - Fax:304-201-1140
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP004544951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical