Healthcare Provider Details

I. General information

NPI: 1700681475
Provider Name (Legal Business Name): ETP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3053 CENTER POINT RD NE STE B
CEDAR RAPIDS IA
52402-4049
US

IV. Provider business mailing address

3053 CENTER POINT RD NE STE B
CEDAR RAPIDS IA
52402-4049
US

V. Phone/Fax

Practice location:
  • Phone: 319-777-9536
  • Fax:
Mailing address:
  • Phone: 319-777-9536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ASHLEY WILLHITE
Title or Position: CREDENTIALING
Credential:
Phone: 319-777-9536