Provider Demographics
NPI:1134667900
Name:JAMES, ETHAN (MAT, ATC)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:JAMES
Suffix:
Gender:M
Credentials:MAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CASTLE CMNS
Mailing Address - Street 2:UNIT C
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-7108
Mailing Address - Country:US
Mailing Address - Phone:937-206-3960
Mailing Address - Fax:
Practice Address - Street 1:515 READ ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1739
Practice Address - Country:US
Practice Address - Phone:812-424-9291
Practice Address - Fax:812-421-2722
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002454A405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN36002454AOtherSTATE OF INDIANA