Provider Demographics
NPI:1518027564
Name:SEIDMAN, ETHAN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:L
Last Name:SEIDMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 61
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3067
Mailing Address - Country:US
Mailing Address - Phone:617-388-7920
Mailing Address - Fax:952-487-2740
Practice Address - Street 1:875 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 61
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3067
Practice Address - Country:US
Practice Address - Phone:617-388-7920
Practice Address - Fax:952-487-2740
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8218103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW51471Medicare ID - Type Unspecified