MEDICARE: DR. LARRY D. ETTER PH.D, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	12043	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609885391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY D. ETTER PH.D, LPC

Provider Business Mailing Address
First Line	:	10010 SAN PEDRO AVE
Second Line	:	# 610
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-3862
Country	:	US
Telephone Number	:	210-414-3259
Fax Number	:	210-222-8030

Provider Business Practice Location Address
First Line	:	10010 SAN PEDRO AVE
Second Line	:	# 610
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-3862
Country	:	US
Telephone Number	:	210-414-3259
Fax Number	:	210-222-8030

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	07/21/2011

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Directions to “ DR. LARRY D. ETTER PH.D, LPC” Practice Location

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