Provider Demographics
NPI:1467178558
Name:BABCOCK, ETHAN JACOB
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:JACOB
Last Name:BABCOCK
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 1:600 W EMBARGO ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-3153
Mailing Address - Country:US
Mailing Address - Phone:315-360-8084
Mailing Address - Fax:
Practice Address - Street 1:600 W EMBARGO ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-3153
Practice Address - Country:US
Practice Address - Phone:315-360-8084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation