Provider Demographics
NPI:1689024986
Name:LIGHT, ETHAN DANIEL (AUD)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:DANIEL
Last Name:LIGHT
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10881 W. ASBURY AVE.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80227
Mailing Address - Country:US
Mailing Address - Phone:303-985-4423
Mailing Address - Fax:303-985-4459
Practice Address - Street 1:10881 W. ASBURY AVE.
Practice Address - Street 2:SUITE 110
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80227
Practice Address - Country:US
Practice Address - Phone:303-985-4423
Practice Address - Fax:303-985-4459
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR030856231H00000X
CO843231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR188692Medicare PIN
ORR188663Medicare PIN
ORR188693Medicare PIN