Provider Demographics
NPI:1609345487
Name:HANCOCK, ETHAN DANIEL
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:DANIEL
Last Name:HANCOCK
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 1:590 PIT RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-7830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:590 PIT RD
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-7830
Practice Address - Country:US
Practice Address - Phone:317-456-1056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-21
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IN05014434A2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty