Provider Demographics
NPI:1073284634
Name:DAHLBERG, ETHAN
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:DAHLBERG
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 1:5360 N ACADEMY BLVD STE 290
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4038
Mailing Address - Country:US
Mailing Address - Phone:719-434-2160
Mailing Address - Fax:
Practice Address - Street 1:5360 N ACADEMY BLVD STE 290
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4038
Practice Address - Country:US
Practice Address - Phone:719-286-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0019385101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional