Provider Demographics
NPI:1033781240
Name:PROTZEL, ETHAN NATHANIEL
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:NATHANIEL
Last Name:PROTZEL
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:PO BOX 1106
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-1106
Mailing Address - Country:US
Mailing Address - Phone:573-290-2338
Mailing Address - Fax:
Practice Address - Street 1:200 E RAMSEY RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-4607
Practice Address - Country:US
Practice Address - Phone:210-490-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-17-46990106S00000X
RBT-21-175744106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician