Provider Demographics
NPI:1457688798
Name:LANGSTON, ETHAN MARTIN
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:MARTIN
Last Name:LANGSTON
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 1:5087 FLAMINGO ROAD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2714 UNION EXTENDED
Practice Address - Street 2:SUITE 400
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112
Practice Address - Country:US
Practice Address - Phone:901-320-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health