Provider Demographics
NPI:1194202747
Name:HENDERSON, ETHAN RAY
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:RAY
Last Name:HENDERSON
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 1:5709 W SUNSET HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99224-9446
Mailing Address - Country:US
Mailing Address - Phone:209-743-8055
Mailing Address - Fax:
Practice Address - Street 1:5709 W SUNSET HWY STE 100
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99224-9446
Practice Address - Country:US
Practice Address - Phone:206-388-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst