Basic Information
| Provider Information | |||||||||
| NPI: | 1497063424 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETLING | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | WEBSTER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 S POWER RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852979283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809260644 | ||||||||
| FaxNumber: | 4809260645 | ||||||||
| Practice Location | |||||||||
| Address1: | 7400 S POWER RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852979283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809260644 | ||||||||
| FaxNumber: | 4809260645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2010 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 4204 | AZ | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 644018 | 05 | AZ | MEDICAID |