Provider Demographics
NPI:1932384351
Name:ETTA ETTLINGER, LCSW, PA
Entity Type:Organization
Organization Name:ETTA ETTLINGER, LCSW, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:ETTA
Authorized Official - Middle Name:F
Authorized Official - Last Name:ETTLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:904-273-4099
Mailing Address - Street 1:100 EXECUTIVE WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4753
Mailing Address - Country:US
Mailing Address - Phone:904-273-4099
Mailing Address - Fax:904-273-4095
Practice Address - Street 1:100 EXECUTIVE WAY STE 110
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-4753
Practice Address - Country:US
Practice Address - Phone:904-273-4099
Practice Address - Fax:904-273-4095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW63101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ003PAMedicare UPIN