Provider Demographics
NPI:1528576980
Name:THOMPSON, ETHAN
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:THOMPSON
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 1:16782 VON KARMAN AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1887 MONTEREY HWY STE 225
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-6117
Practice Address - Country:US
Practice Address - Phone:855-223-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician