Healthcare Provider Details

I. General information

NPI: 1447571062
Provider Name (Legal Business Name): SCOTT ALAN ETHUN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 03/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W LAKE ST
FRIENDSHIP WI
53934
US

IV. Provider business mailing address

JUNEAU COUNTY DEPT OF HUMAN SERVICES 200 HICKORY ST
MAUSTON WI
53948
US

V. Phone/Fax

Practice location:
  • Phone: 608-474-4355
  • Fax:
Mailing address:
  • Phone: 608-847-2400
  • Fax: 608-847-9421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2217-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: