Provider Demographics
NPI:1457823411
Name:BLACKSTONE, ETHAN JON (MFTA)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:JON
Last Name:BLACKSTONE
Suffix:
Gender:M
Credentials:MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 SOUTHCENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14216 NE 21ST ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3720
Practice Address - Country:US
Practice Address - Phone:425-653-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2020-10-13
Deactivation Date:2020-09-30
Deactivation Code:
Reactivation Date:2020-10-09
Provider Licenses
StateLicense IDTaxonomies
WA101Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program