Provider Demographics
NPI:1487789624
Name:ETHERTON, JOSEPH (PHD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:ETHERTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JOE
Other - Middle Name:
Other - Last Name:ETHERTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1008 MOPAC CIRCLE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746
Mailing Address - Country:US
Mailing Address - Phone:512-982-9273
Mailing Address - Fax:504-780-1705
Practice Address - Street 1:1008 MOPAC CIRCLE
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746
Practice Address - Country:US
Practice Address - Phone:512-982-9273
Practice Address - Fax:504-780-1705
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA863103T00000X
TX32701103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C154Medicare ID - Type Unspecified