Provider Demographics
NPI:1588150148
Name:ETZEL, DEDRA DEHAVEN (MS, LPC)
Entity type:Individual
Prefix:
First Name:DEDRA
Middle Name:DEHAVEN
Last Name:ETZEL
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 CARRIAGE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-5133
Mailing Address - Country:US
Mailing Address - Phone:713-516-3698
Mailing Address - Fax:
Practice Address - Street 1:16815 ROYAL CREST DR STE 160
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2534
Practice Address - Country:US
Practice Address - Phone:281-407-5658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-07
Last Update Date:2018-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71234101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional