Provider Demographics
NPI:1578104345
Name:MESSENGER, ETHAN R
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:R
Last Name:MESSENGER
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 1:1260 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17202-9723
Mailing Address - Country:US
Mailing Address - Phone:717-448-6780
Mailing Address - Fax:
Practice Address - Street 1:20 E BURD ST STE 1
Practice Address - Street 2:
Practice Address - City:SHIPPENSBURG
Practice Address - State:PA
Practice Address - Zip Code:17257-1328
Practice Address - Country:US
Practice Address - Phone:717-477-2556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011433101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health