MEDICARE: DAWN LESLEY ETZEL

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	86000311A	IN
2	101YM0800X	Mental Health Counselor	39002304A	IN

General Provider Information

NPI Number	:	1912213588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAWN LESLEY ETZEL

Provider Business Mailing Address
First Line	:	1747 N WELLS ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-3235
Country	:	US
Telephone Number	:	260-420-6100
Fax Number	:	574-268-2377

Provider Business Practice Location Address
First Line	:	1747 N WELLS ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-3235
Country	:	US
Telephone Number	:	260-420-6100
Fax Number	:	574-268-2377

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

Provider Enumeration Date	:	08/20/2010
Last Update Date	:	04/09/2024

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Directions to “ DAWN LESLEY ETZEL ” Practice Location

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