Provider Demographics
NPI:1043743537
Name:AMDAHL, ETHAN CALEB (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:CALEB
Last Name:AMDAHL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 808 BOX 19
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09618-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:U.S. NAVAL HOPSITAL
Practice Address - Street 2:VIA CONTRADA BOSCARIELLO
Practice Address - City:GRICIGNANO DI AVERSA
Practice Address - State:CE
Practice Address - Zip Code:81030
Practice Address - Country:IT
Practice Address - Phone:081-811-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007593103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical