Healthcare Provider Details

I. General information

NPI: 1740906817
Provider Name (Legal Business Name): ANTHONY J ETIENNE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 SE 4TH TER
DANIA BEACH FL
33004-4139
US

IV. Provider business mailing address

350 FAIRWAY DR
DEERFIELD BEACH FL
33441-1834
US

V. Phone/Fax

Practice location:
  • Phone: 754-256-7858
  • Fax:
Mailing address:
  • Phone: 877-418-2978
  • Fax: 866-500-2186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1092392
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: