MEDICARE: STEPHANIE ETKIN HART LPC-I

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	76587	TX

General Provider Information

NPI Number	:	1598202715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE ETKIN HART LPC-I

Provider Business Mailing Address
First Line	:	2113 BROOKLYN ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-4324
Country	:	US
Telephone Number	:	512-534-6188
Fax Number	:

Provider Business Practice Location Address
First Line	:	2113 BROOKLYN ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-4324
Country	:	US
Telephone Number	:	512-534-6188
Fax Number	:

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

Provider Enumeration Date	:	01/25/2017
Last Update Date	:	01/25/2017

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