Provider Demographics
NPI:1164010781
Name:DUCLOS, ETHAN LOUIS (DPT)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:LOUIS
Last Name:DUCLOS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 STATE ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-4037
Mailing Address - Country:US
Mailing Address - Phone:618-977-7415
Mailing Address - Fax:
Practice Address - Street 1:3507 STATE ROUTE 3
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-4037
Practice Address - Country:US
Practice Address - Phone:618-977-7415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist