Provider Demographics
NPI:1003315730
Name:STEIN, ETHAN ZACHARY
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:ZACHARY
Last Name:STEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MICHELLE
Other - Last Name:STEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:460 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-8130
Mailing Address - Country:US
Mailing Address - Phone:617-847-1950
Mailing Address - Fax:617-774-1490
Practice Address - Street 1:460 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-8130
Practice Address - Country:US
Practice Address - Phone:978-387-9023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health