Provider Demographics
NPI:1033729272
Name:NAVARRO, ETHAN BURT (MED CF-SLP)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:BURT
Last Name:NAVARRO
Suffix:
Gender:M
Credentials:MED CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 MEMORIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1708
Mailing Address - Country:US
Mailing Address - Phone:434-845-8765
Mailing Address - Fax:
Practice Address - Street 1:1912 MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1708
Practice Address - Country:US
Practice Address - Phone:434-845-8765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000571235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist