Provider Demographics
NPI:1740788959
Name:SPICER, ETHAN COLE
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:COLE
Last Name:SPICER
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 1:1330 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TENNESSEE RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37178-4003
Mailing Address - Country:US
Mailing Address - Phone:931-721-3312
Mailing Address - Fax:
Practice Address - Street 1:1330 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TENNESSEE RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37178-4003
Practice Address - Country:US
Practice Address - Phone:931-721-3312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health