Provider Demographics
NPI:1043975915
Name:KOROTZER, ETHAN MICHAEL
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:MICHAEL
Last Name:KOROTZER
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 1:32 WOODSTREAM CT
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2713
Mailing Address - Country:US
Mailing Address - Phone:315-235-7629
Mailing Address - Fax:
Practice Address - Street 1:1550 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4828
Practice Address - Country:US
Practice Address - Phone:315-235-7629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0551921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical