Provider Demographics
NPI:1407517402
Name:FARRIS, DOMINICK ETHAN
Entity Type:Individual
Prefix:MR
First Name:DOMINICK
Middle Name:ETHAN
Last Name:FARRIS
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 1:4501 SAN IGNACIO APT E113
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4085
Mailing Address - Country:US
Mailing Address - Phone:505-946-7781
Mailing Address - Fax:
Practice Address - Street 1:4501 SAN IGNACIO APT E113
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4085
Practice Address - Country:US
Practice Address - Phone:505-946-7781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician