Provider Demographics
NPI:1215583067
Name:BARDELL, ETHAN
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:BARDELL
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 1:165 MAIN ST
Mailing Address - Street 2:STE A
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-3049
Mailing Address - Country:US
Mailing Address - Phone:607-753-0234
Mailing Address - Fax:
Practice Address - Street 1:165 MAIN ST
Practice Address - Street 2:STE A
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-3049
Practice Address - Country:US
Practice Address - Phone:607-753-0234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101837101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor