Provider Demographics
NPI:1033364799
Name:ETHAN, BARBARA (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:BARBARA
Middle Name:
Last Name:ETHAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 RONDOUT HBR
Mailing Address - Street 2:
Mailing Address - City:PORT EWEN
Mailing Address - State:NY
Mailing Address - Zip Code:12466-5001
Mailing Address - Country:US
Mailing Address - Phone:845-334-8628
Mailing Address - Fax:845-334-8628
Practice Address - Street 1:28 RONDOUT HBR
Practice Address - Street 2:
Practice Address - City:PORT EWEN
Practice Address - State:NY
Practice Address - Zip Code:12466-5001
Practice Address - Country:US
Practice Address - Phone:845-334-8628
Practice Address - Fax:845-334-8628
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-22
Last Update Date:2008-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003917-1171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid