Provider Demographics
NPI:1659723393
Name:PRAVETZ, ETHAN THOMAS (PT, DPT, CCI)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:THOMAS
Last Name:PRAVETZ
Suffix:
Gender:M
Credentials:PT, DPT, CCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 AMSTERDAM AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 CARNEGIE PLZ
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-1000
Practice Address - Country:US
Practice Address - Phone:877-407-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0124005225100000X
NH4111225100000X
MA22214225100000X
NY042312-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist