Basic Information
| Provider Information | |||||||||
| NPI: | 1932293693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETZEL | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1169 EASTERN PKWY | ||||||||
| Address2: | SUITE 2266 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402171417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022383178 | ||||||||
| FaxNumber: | 5022383653 | ||||||||
| Practice Location | |||||||||
| Address1: | 1169 EASTERN PKWY | ||||||||
| Address2: | SUITE 3357 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402171417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024540755 | ||||||||
| FaxNumber: | 5024791231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 06/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1616 | KY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1616 | 01 | KY | KY PSYCHOLOGY LICENSE | OTHER | 071-007127 | 01 | IL | IL STATE LIC | OTHER |