Provider Demographics
NPI:1114527116
Name:ARLT, ETHAN ANTHONY
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:ANTHONY
Last Name:ARLT
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 1:201 W MAIN ST STE 4B
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-2734
Mailing Address - Country:US
Mailing Address - Phone:541-414-1720
Mailing Address - Fax:
Practice Address - Street 1:1836 FREMONT ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2537
Practice Address - Country:US
Practice Address - Phone:541-482-5792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health