Provider Demographics
NPI:1467962928
Name:BANNAR, ETHAN SCOTT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:SCOTT
Last Name:BANNAR
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 FT RICHARDSON AVE
Mailing Address - Street 2:
Mailing Address - City:GOODFELLOW AIR FORCE BASE
Mailing Address - State:TX
Mailing Address - Zip Code:76908
Mailing Address - Country:US
Mailing Address - Phone:325-654-3122
Mailing Address - Fax:325-654-5161
Practice Address - Street 1:271 FT RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:GOODFELLOW AFB
Practice Address - State:TX
Practice Address - Zip Code:76908
Practice Address - Country:US
Practice Address - Phone:325-654-3122
Practice Address - Fax:325-654-5161
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X
VA0810007978103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program