MEDICARE: ETTA ETTLINGER, LCSW, PA

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	1041C0700X	Clinical Social Worker	SW6310	FL

General Provider Information

NPI Number	:	1932384351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETTA ETTLINGER, LCSW, PA

Provider Business Mailing Address
First Line	:	100 EXECUTIVE WAY STE 110
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32082-4753
Country	:	US
Telephone Number	:	904-273-4099
Fax Number	:	904-273-4095

Provider Business Practice Location Address
First Line	:	100 EXECUTIVE WAY STE 110
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32082-4753
Country	:	US
Telephone Number	:	904-273-4099
Fax Number	:	904-273-4095

Authorized Official
Title or Position	:	CLINICAL SOCIAL WORKER
Name	:	MS. ETTA F. ETTLINGER
Credential	:	LCSW
Telephone Number	:	904-273-4099

Provider Enumeration Date	:	01/03/2008
Last Update Date	:	01/03/2008

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