MEDICARE: AMANDA ETIENNE

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	103TC0700X	Clinical Psychologist	PSY0006408	CO

General Provider Information

NPI Number	:	1922584283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA ETIENNE

Provider Business Mailing Address
First Line	:	1090 S WADSWORTH BLVD STE C
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80226-4350
Country	:	US
Telephone Number	:	914-620-2405
Fax Number	:

Provider Business Practice Location Address
First Line	:	1090 S WADSWORTH BLVD STE C3096
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80226-4328
Country	:	US
Telephone Number	:	914-620-2405
Fax Number	:

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

Provider Enumeration Date	:	07/19/2018
Last Update Date	:	04/27/2024

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Directions to “ AMANDA ETIENNE ” Practice Location

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