Provider Demographics
NPI:1033585138
Name:COVALT, ETHAN
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:COVALT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 MAIN LINE DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17044-8127
Mailing Address - Country:US
Mailing Address - Phone:717-462-0372
Mailing Address - Fax:
Practice Address - Street 1:403 6TH ST
Practice Address - Street 2:BOX 870
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-1518
Practice Address - Country:US
Practice Address - Phone:877-312-6576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI004324225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant