Provider Demographics
NPI:1710335484
Name:HOCCOM, ETHAN WILLIAM
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:WILLIAM
Last Name:HOCCOM
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 1:1527 NE LA MESA PL
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-4540
Mailing Address - Country:US
Mailing Address - Phone:971-337-4111
Mailing Address - Fax:
Practice Address - Street 1:1527 NE LAMESA PLACE 17TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:971-337-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor