Provider Demographics
NPI:1871711887
Name:ETTEL, THERESE DOLORES (PSYD)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:DOLORES
Last Name:ETTEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 DURLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102
Mailing Address - Country:US
Mailing Address - Phone:406-655-3460
Mailing Address - Fax:
Practice Address - Street 1:902 WYOMING AVENUE
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101
Practice Address - Country:US
Practice Address - Phone:406-254-0192
Practice Address - Fax:406-254-0091
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT259103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0492235Medicaid